Healthcare Provider Details

I. General information

NPI: 1700769023
Provider Name (Legal Business Name): JORDAN KOCIAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2025
Last Update Date: 07/22/2026
Certification Date: 07/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 BRUSHY CREEK RD
TAYLORS SC
29687-4007
US

IV. Provider business mailing address

4807 OLD SPARTANBURG RD APT 1600G
TAYLORS SC
29687-4261
US

V. Phone/Fax

Practice location:
  • Phone: 402-840-3168
  • Fax:
Mailing address:
  • Phone: 402-840-3168
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2273
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: