Healthcare Provider Details

I. General information

NPI: 1396192795
Provider Name (Legal Business Name): JORDAN D AZINGER PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2016
Last Update Date: 05/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2116 BUECHEL BANK RD
LOUISVILLE KY
40218-3521
US

IV. Provider business mailing address

9903 CLUB SPRINGS WAY UNIT 104
LOUISVILLE KY
40291-4216
US

V. Phone/Fax

Practice location:
  • Phone: 502-488-9383
  • Fax:
Mailing address:
  • Phone: 502-572-4735
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberT1606
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: