Provider Demographics
NPI:1487761979
Name:BLACKETER, JODI MARIE (PT)
Entity type:Individual
Prefix:
First Name:JODI
Middle Name:MARIE
Last Name:BLACKETER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:JODI
Other - Middle Name:MARIE
Other - Last Name:BOYD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:6033 W INTERSTATE 20
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76017-1042
Mailing Address - Country:US
Mailing Address - Phone:817-483-1746
Mailing Address - Fax:817-483-5874
Practice Address - Street 1:6033 W INTERSTATE 20
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76017-1042
Practice Address - Country:US
Practice Address - Phone:817-483-1746
Practice Address - Fax:817-483-5874
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2022-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1132405225100000X
225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1132405OtherLICENSE #
TXTXB107196Medicare PIN