Healthcare Provider Details

I. General information

NPI: 1629643275
Provider Name (Legal Business Name): JORDAN PAIGE GOODMAN CRT, RRT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2021
Last Update Date: 05/26/2021
Certification Date: 05/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5579 S ORANGE AVE
EDGEWOOD FL
32809-3493
US

IV. Provider business mailing address

514 MOUNT PLEASANT RD
WHITEVILLE TN
38075-6243
US

V. Phone/Fax

Practice location:
  • Phone: 407-241-4800
  • Fax:
Mailing address:
  • Phone: 731-234-2225
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code227900000X
TaxonomyRegistered Respiratory Therapist
License Number179609
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: