Healthcare Provider Details

I. General information

NPI: 1205615689
Provider Name (Legal Business Name): JORDAN NICOLE HANNER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2023
Last Update Date: 09/29/2026
Certification Date: 09/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 CRISANTO AVE STE A
FORT MILL SC
29715-6272
US

IV. Provider business mailing address

PO BOX 412066
BOSTON MA
02241-2066
US

V. Phone/Fax

Practice location:
  • Phone: 803-746-7800
  • Fax:
Mailing address:
  • Phone: 914-294-4050
  • Fax: 631-760-8306

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number13594
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5501302435
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: