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General NPI Number Information
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NPI Number | 1538737101
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Entity Type | Individual
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Provider Name | JORDAN WINES AU.D.
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Gender | Male
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Dates
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Enumeration Date | 06/11/2021
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Last Update Date | 05/03/2023
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Provider Practice Location Address
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Address Line | 106 E WATAUGA AVE
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City | JOHNSON CITY
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State | TN
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Zip | 37601-4628
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Country | US
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Telephone | 423-928-5771
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Fax | 423-928-1424
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Provider Business Mailing Address
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Address Line | 106 E WATAUGA AVE
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City | JOHNSON CITY
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State | TN
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Zip | 37601-4628
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Country | US
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Telephone | 423-928-5771
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Fax | 423-928-1424
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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 | 231H00000X
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Taxonomy Name | Audiologist
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License Number | 2091
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License Number State | TN
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