Basic Information
| Provider Information | |||||||||
| NPI: | 1508807967 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROBESON | ||||||||
| FirstName: | JODY | ||||||||
| MiddleName: | S. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SHANKS | ||||||||
| OtherFirstName: | JODY | ||||||||
| OtherMiddleName: | L. | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | P.O. BOX 2805 | ||||||||
| Address2: | |||||||||
| City: | BANDERA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 780032805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8307963447 | ||||||||
| FaxNumber: | 8307963685 | ||||||||
| Practice Location | |||||||||
| Address1: | 3456 STATE HIGHWAY 16 SOUTH | ||||||||
| Address2: | |||||||||
| City: | BANDERA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 78003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8307963447 | ||||||||
| FaxNumber: | 8307963685 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2006 | ||||||||
| LastUpdateDate: | 06/12/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 1159443 | TX | N | Other Service Providers | Specialist | 225100000X | 1159443 | TX | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 1159443 | 01 | TX | STATE LICENSE | OTHER |