Healthcare Provider Details

I. General information

NPI: 1841775418
Provider Name (Legal Business Name): MRS. JORDAN JOSEPH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/30/2018
Last Update Date: 07/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

516 N 14TH ST APT 12
MANHATTAN KS
66502-4172
US

IV. Provider business mailing address

1200 CORPORATE DR STE 400
BIRMINGHAM AL
35242-5424
US

V. Phone/Fax

Practice location:
  • Phone: 913-246-2624
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2529
License Number StateTN

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: