Healthcare Provider Details

I. General information

NPI: 1053039388
Provider Name (Legal Business Name): JORDAN JENKINS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2022
Last Update Date: 08/22/2022
Certification Date: 08/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 E NORTHSIDE DR
CLINTON MS
39056-3604
US

IV. Provider business mailing address

599C STEED RD
RIDGELAND MS
39157-1707
US

V. Phone/Fax

Practice location:
  • Phone: 601-924-0645
  • Fax: 601-607-1375
Mailing address:
  • Phone: 601-605-6777
  • Fax: 601-813-5460

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT7422
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: