Provider Demographics
NPI:1114305620
Name:LIGHT, JORDAN
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:LIGHT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 MACKLEM DR
Mailing Address - Street 2:
Mailing Address - City:WILMORE
Mailing Address - State:KY
Mailing Address - Zip Code:40390-1152
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 MACKLEM DR
Practice Address - Street 2:
Practice Address - City:WILMORE
Practice Address - State:KY
Practice Address - Zip Code:40390-1152
Practice Address - Country:US
Practice Address - Phone:360-773-0106
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-16
Last Update Date:2015-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYAT11742255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer