Basic Information
| Provider Information | |||||||||
| NPI: | 1992800551 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CROCKETT | ||||||||
| FirstName: | JODI | ||||||||
| MiddleName: | LYNN | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 500 CROSS ST | ||||||||
| Address2: | |||||||||
| City: | BIG STONE CITY | ||||||||
| State: | SD | ||||||||
| PostalCode: | 572168237 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6055411140 | ||||||||
| FaxNumber: | 2182338545 | ||||||||
| Practice Location | |||||||||
| Address1: | 2401 41ST ST S | ||||||||
| Address2: | |||||||||
| City: | FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 581047783 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7014787868 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2006 | ||||||||
| LastUpdateDate: | 03/04/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 6503 | MN | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 1288 | ND | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 55086 | 05 | ND | MEDICAID | 318295900 | 05 | MN | MEDICAID |