Healthcare Provider Details

I. General information

NPI: 1467079483
Provider Name (Legal Business Name): JORDAN R FAULKNER DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2020
Last Update Date: 06/26/2020
Certification Date: 06/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

703 CLINTON PKWY
CLINTON MS
39056-5245
US

IV. Provider business mailing address

8205 PRESIDENTS DR
HUMMELSTOWN PA
17036-8621
US

V. Phone/Fax

Practice location:
  • Phone: 601-708-4205
  • Fax: 601-708-4707
Mailing address:
  • Phone: 717-839-2188
  • Fax: 717-565-1104

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT5995
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: