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General NPI Number Information
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NPI Number | 1457730335
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Entity Type | Individual
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Provider Name | JORDAN DAVID PRIEBE PTA
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Gender | Male
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Dates
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Enumeration Date | 05/25/2015
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Last Update Date | 05/25/2015
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Provider Practice Location Address
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Address Line | 5245 N SOCRUM LOOP RD
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City | LAKELAND
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State | FL
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Zip | 33809-4253
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Country | US
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Telephone | 863-859-1446
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Fax |
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Provider Business Mailing Address
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Address Line | 16744 CAGAN CROSSINGS BLVD APT. 7
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City | CLERMONT
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State | FL
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Zip | 34714-4886
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Country | US
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Telephone | 321-439-1356
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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 | 225200000X
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Taxonomy Name | Physical Therapy Assistant
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License Number | 25673
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License Number State | FL
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