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General NPI Number Information
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NPI Number | 1558739128
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Entity Type | Individual
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Provider Name | JORDAN DORRIEN ATC
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Gender | Male
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Dates
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Enumeration Date | 09/12/2015
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Last Update Date | 09/12/2015
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Provider Practice Location Address
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Address Line | 402 BLUEBIRD BLVD
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City | FORT VALLEY
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State | GA
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Zip | 31030-5088
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Country | US
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Telephone | 478-825-2021
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Fax |
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Provider Business Mailing Address
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Address Line | 800 GUNN RD APT. 1028
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City | CENTERVILLE
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State | GA
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Zip | 31028-8556
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Country | US
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Telephone | 973-879-5172
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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 | AT002316
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License Number State | GA
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