Healthcare Provider Details

I. General information

NPI: 1760128003
Provider Name (Legal Business Name): JORDAN BLAKE MCCASKILL DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2022
Last Update Date: 05/10/2022
Certification Date: 05/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2060 RHINO XING
MILAN TN
38358-5201
US

IV. Provider business mailing address

PO BOX 1004
MILAN TN
38358-1004
US

V. Phone/Fax

Practice location:
  • Phone: 731-613-2214
  • Fax: 731-613-2215
Mailing address:
  • Phone: 731-613-2214
  • Fax: 731-613-2215

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number14053
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: