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: 07/30/2026
Certification Date: 07/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

98 SHELBY SPEIGHTS DR
PURVIS MS
39475-4528
US

IV. Provider business mailing address

415 S 28TH AVE
HATTIESBURG MS
39401-7246
US

V. Phone/Fax

Practice location:
  • Phone: 601-794-2402
  • Fax: 601-794-2404
Mailing address:
  • Phone: 601-264-6000
  • Fax: 601-794-2404

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: