Healthcare Provider Details

I. General information

NPI: 1467374801
Provider Name (Legal Business Name): JORDAN BLUE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/28/2026
Last Update Date: 07/28/2026
Certification Date: 07/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1261 BELL RD
CHAGRIN FALLS OH
44022-4253
US

IV. Provider business mailing address

1261 BELL RD
CHAGRIN FALLS OH
44022-4253
US

V. Phone/Fax

Practice location:
  • Phone: 216-271-1133
  • Fax: 216-271-1325
Mailing address:
  • Phone: 216-271-1133
  • Fax: 216-271-1325

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA013722
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: