Provider Demographics
NPI:1184123515
Name:BIELICKE, JODI (DPT)
Entity type:Individual
Prefix:
First Name:JODI
Middle Name:
Last Name:BIELICKE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:JODI
Other - Middle Name:
Other - Last Name:KLOTT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4273 KEATON CROSSING BLVD
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:MO
Mailing Address - Zip Code:63368-8220
Mailing Address - Country:US
Mailing Address - Phone:636-206-6540
Mailing Address - Fax:
Practice Address - Street 1:15425 MANCHESTER RD STE 28
Practice Address - Street 2:
Practice Address - City:BALLWIN
Practice Address - State:MO
Practice Address - Zip Code:63011-3077
Practice Address - Country:US
Practice Address - Phone:636-467-2730
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-12
Last Update Date:2021-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018003429225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist