MEDICARE: JORDAN M MAHAN PT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	29666	FL

General Provider Information

NPI Number	:	1679253025
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JORDAN M MAHAN PT

Provider Business Mailing Address
First Line	:	530 SE 16TH PL
Second Line	:
City	:	CAPE CORAL
State	:	FL
Zip	:	33990-1656
Country	:	US
Telephone Number	:	239-800-3814
Fax Number	:	239-800-3820

Provider Business Practice Location Address
First Line	:	530 SE 16TH PL
Second Line	:
City	:	CAPE CORAL
State	:	FL
Zip	:	33990-1656
Country	:	US
Telephone Number	:	239-800-3814
Fax Number	:	239-800-3820

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/20/2023
Last Update Date	:	07/20/2023

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