Basic Information
| Provider Information | |||||||||
| NPI: | 1447503198 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAVENPORT | ||||||||
| FirstName: | MARY JO | ||||||||
| MiddleName: | |||||||||
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| Credential: | PT, MS, PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 807 UNIVERSITY PKWY | ||||||||
| Address2: | BOX 70403 | ||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376141703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4234394071 | ||||||||
| FaxNumber: | 4234394060 | ||||||||
| Practice Location | |||||||||
| Address1: | 807 UNIVERSITY PKWY | ||||||||
| Address2: | BOX 70403 | ||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376141703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4234394071 | ||||||||
| FaxNumber: | 4234394060 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/18/2012 | ||||||||
| LastUpdateDate: | 10/18/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT867 | TN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | PT867 | 01 | TN | ST LIC | OTHER |