Healthcare Provider Details

I. General information

NPI: 1922288083
Provider Name (Legal Business Name): ELLEN JORDAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/06/2007
Last Update Date: 07/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4109 HIGHWAY 98 W
SUMMIT MS
39666-9132
US

IV. Provider business mailing address

4109 HIGHWAY 98 W
SUMMIT MS
39666-9132
US

V. Phone/Fax

Practice location:
  • Phone: 601-683-6644
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number3887
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: