Healthcare Provider Details

I. General information

NPI: 1073157699
Provider Name (Legal Business Name): JORDIN ASHLEE BROUHARD ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/06/2019
Last Update Date: 11/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13847 W 63RD ST STE 2
SHAWNEE KS
66216-3800
US

IV. Provider business mailing address

6397 LEE HWY STE 300
CHATTANOOGA TN
37421-4915
US

V. Phone/Fax

Practice location:
  • Phone: 913-962-7770
  • Fax: 913-962-7775
Mailing address:
  • Phone: 423-238-7217
  • Fax: 423-238-3473

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2019032147
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number24-01036
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: