Provider Demographics
NPI:1447503198
Name:DAVENPORT, MARY JO (PT, MS, PHD)
Entity type:Individual
Prefix:
First Name:MARY JO
Middle Name:
Last Name:DAVENPORT
Suffix:
Gender:F
Credentials:PT, MS, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:807 UNIVERSITY PKWY
Mailing Address - Street 2:BOX 70403
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37614-1703
Mailing Address - Country:US
Mailing Address - Phone:423-439-4071
Mailing Address - Fax:423-439-4060
Practice Address - Street 1:807 UNIVERSITY PKWY
Practice Address - Street 2:BOX 70403
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37614-1703
Practice Address - Country:US
Practice Address - Phone:423-439-4071
Practice Address - Fax:423-439-4060
Is Sole Proprietor?:No
Enumeration Date:2012-10-18
Last Update Date:2012-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPT867225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNPT867OtherST LIC