MEDICARE: BRYONNA JORDAN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	224Z00000X	Occupational Therapy Assistant	5600	SC

General Provider Information

NPI Number	:	1023899564
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRYONNA JORDAN

Provider Business Mailing Address
First Line	:	1785 RESERVATION RD
Second Line	:
City	:	ROCK HILL
State	:	SC
Zip	:	29730-9584
Country	:	US
Telephone Number	:	803-230-8402
Fax Number	:

Provider Business Practice Location Address
First Line	:	2681 LENGERS WAY
Second Line	:
City	:	INDIAN LAND
State	:	SC
Zip	:	29707-4200
Country	:	US
Telephone Number	:	803-877-6408
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/10/2023
Last Update Date	:	10/10/2023

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