Provider Demographics
NPI:1083873079
Name:JORDAN, NANCY CAROL
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:CAROL
Last Name:JORDAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ELMA
Mailing Address - State:WA
Mailing Address - Zip Code:98541-9560
Mailing Address - Country:US
Mailing Address - Phone:360-346-2299
Mailing Address - Fax:360-346-2157
Practice Address - Street 1:1809 COOKS HILL RD
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:WA
Practice Address - Zip Code:98531-9072
Practice Address - Country:US
Practice Address - Phone:360-330-8844
Practice Address - Fax:360-330-8623
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-04
Last Update Date:2018-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00006277225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist