Provider Demographics
NPI:1881759645
Name:BULLARD, JODY ALISON THATCHER (PT)
Entity type:Individual
Prefix:MS
First Name:JODY
Middle Name:ALISON THATCHER
Last Name:BULLARD
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MS
Other - First Name:JODY
Other - Middle Name:ALISON
Other - Last Name:THATCHER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PT
Mailing Address - Street 1:2302 N BOGUS BASIN RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-0902
Mailing Address - Country:US
Mailing Address - Phone:208-344-0737
Mailing Address - Fax:208-344-0759
Practice Address - Street 1:2302 N BOGUS BASIN RD
Practice Address - Street 2:SUITE C
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-0902
Practice Address - Country:US
Practice Address - Phone:208-344-0737
Practice Address - Fax:208-344-0759
Is Sole Proprietor?:No
Enumeration Date:2006-12-22
Last Update Date:2010-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-1137225100000X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807030700Medicaid
ID1655519Medicare ID - Type Unspecified