Healthcare Provider Details

I. General information

NPI: 1841702123
Provider Name (Legal Business Name): JODY THOMAS BANCROFT PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2017
Last Update Date: 10/26/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8507 NE 8TH WAY
VANCOUVER WA
98664-1980
US

IV. Provider business mailing address

115 E 35TH ST
VANCOUVER WA
98663-2206
US

V. Phone/Fax

Practice location:
  • Phone: 360-254-5335
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberP160775448
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: