Provider Demographics
NPI:1003373085
Name:MCCOWEN, JORDAN NICOLE (DPT)
Entity Type:Individual
Prefix:MRS
First Name:JORDAN
Middle Name:NICOLE
Last Name:MCCOWEN
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:MISS
Other - First Name:JORDAN
Other - Middle Name:NICOLE
Other - Last Name:PORTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2 HARBOR BEND CT STE 102
Mailing Address - Street 2:
Mailing Address - City:LAKE SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63367-1480
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2 HARBOR BEND CT STE 102
Practice Address - Street 2:
Practice Address - City:LAKE SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63367-1480
Practice Address - Country:US
Practice Address - Phone:636-295-2070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-26
Last Update Date:2019-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018029942225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist