Healthcare Provider Details

I. General information

NPI: 1407114440
Provider Name (Legal Business Name): JODY CARL BENNETT P.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/27/2012
Last Update Date: 08/10/2023
Certification Date: 08/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4010 BIENVILLE BLVD UNIT E
OCEAN SPRINGS MS
39564-5990
US

IV. Provider business mailing address

670 LEIGH DR
COLUMBUS MS
39705-3014
US

V. Phone/Fax

Practice location:
  • Phone: 228-300-6001
  • Fax: 228-300-6005
Mailing address:
  • Phone: 662-328-1012
  • Fax: 662-328-1507

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT3943
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number11395R
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: