Active NPI
Jodi A Boutott, PT
- Physical Therapist
- Clintonville, WI
National Provider Identifier
1184891590
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Physical Therapist
- License
- 5055-024
- Practice address
- 1625 E Main St
Clintonville, WI 54929-8407 - Phone
- (715) 823-3135
- Fax
- (715) 823-1313
- NPI assigned
- May 14, 2008
- Last updated
- Mar 27, 2024
- Sex
- Female
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Physical Therapist | 225100000X | 5055-024 | WI | Primary |
Addresses
Primary practice location
1625 E Main St
Clintonville, WI 54929-8407
Mailing address
1625 E Main St
Clintonville, WI 54929-8407
Phone (715) 823-3135
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 40296200 | Medicaid | WI |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 5055-024 | WI | MD | Physical Therapist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1210723200000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1711497600000",
"number": "1184891590",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "1625 E MAIN ST",
"city": "CLINTONVILLE",
"state": "WI",
"postal_code": "549298407",
"telephone_number": "715-823-3135",
"fax_number": "715-823-1313"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "1625 E MAIN ST",
"city": "CLINTONVILLE",
"state": "WI",
"postal_code": "549298407",
"telephone_number": "715-823-3135",
"fax_number": "715-823-1313"
}
],
"practiceLocations": [],
"basic": {
"last_name": "BOUTOTT",
"first_name": "JODI",
"middle_name": "A",
"credential": "PT",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2008-05-14",
"last_updated": "2024-03-27",
"certification_date": "2024-03-27",
"status": "A"
},
"taxonomies": [
{
"code": "225100000X",
"taxonomy_group": "",
"desc": "Physical Therapist",
"state": "WI",
"license": "5055-024",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "40296200",
"state": "WI"
}
],
"endpoints": [],
"other_names": []
}Other providers in Clintonville, WI
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 27, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.