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General NPI Number Information
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NPI Number | 1316798556
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Entity Type | Individual
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Provider Name | JORDAN WILT
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Gender | Male
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Dates
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Enumeration Date | 03/27/2024
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Last Update Date | 03/27/2024
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Provider Practice Location Address
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Address Line | 11132 MADISON PIKE
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City | INDEPENDENCE
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State | KY
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Zip | 41051-7523
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Country | US
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Telephone | 859-960-0100
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Fax |
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Provider Business Mailing Address
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Address Line | 313 CROSS ST
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City | ELSMERE
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State | KY
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Zip | 41018-2106
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | AT1863
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License Number State | KY
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