Healthcare Provider Details

I. General information

NPI: 1891156170
Provider Name (Legal Business Name): JORDAN TILLEY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2016
Last Update Date: 03/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 EMERALD DR
COLUMBUS MS
39702-5526
US

IV. Provider business mailing address

5622 COUNTY ROAD 30
ETHELSVILLE AL
35461-3301
US

V. Phone/Fax

Practice location:
  • Phone: 662-315-4174
  • Fax:
Mailing address:
  • Phone: 662-315-4174
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA5157
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: