Provider Demographics
NPI:1023235777
Name:BODDU, JAYA PRAKASH (PT)
Entity type:Individual
Prefix:MR
First Name:JAYA
Middle Name:PRAKASH
Last Name:BODDU
Suffix:
Gender:M
Credentials:PT
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Mailing Address - Street 1:1447 E GRAND RIVER AVE
Mailing Address - Street 2:HEALTH SOURCE PHYSICAL THERAPY CENTER,INC.
Mailing Address - City:PORTLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48875-9687
Mailing Address - Country:US
Mailing Address - Phone:517-647-1000
Mailing Address - Fax:517-647-1100
Practice Address - Street 1:1447 E GRAND RIVER AVE
Practice Address - Street 2:HEALTH SOURCE PHYSICAL THERAPY CENTER,INC.
Practice Address - City:PORTLAND
Practice Address - State:MI
Practice Address - Zip Code:48875-9687
Practice Address - Country:US
Practice Address - Phone:517-647-1000
Practice Address - Fax:517-647-1100
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5501005495225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist