Healthcare Provider Details

I. General information

NPI: 1215593843
Provider Name (Legal Business Name): JORDYN WEAVER AT, AT-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2019
Last Update Date: 05/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 MIAMI VALLEY DR # 160
CENTERVILLE OH
45459-4774
US

IV. Provider business mailing address

2007 MIRACLE MILE
SPRINGFIELD OH
45503-2836
US

V. Phone/Fax

Practice location:
  • Phone: 937-312-1661
  • Fax:
Mailing address:
  • Phone: 937-450-4511
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT005307
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: