=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497279301
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JORDAN NICOLE HARDERS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/01/2017
-----------------------------------------------------
Last Update Date | 08/01/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4075 TIMBERLINE ST
-----------------------------------------------------
City | GRAND ISLAND
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68803-6553
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 308-384-3535
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 25117 SW PARKWAY AVE STE D
-----------------------------------------------------
City | WILSONVILLE
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97070-9697
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number | 1332
-----------------------------------------------------
License Number State | NE
-----------------------------------------------------