Provider Demographics
NPI:1164076568
Name:CLEVENGER, JORDAN ALEXANDER (DPT)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:ALEXANDER
Last Name:CLEVENGER
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10876 COLD SPRING DR
Mailing Address - Street 2:
Mailing Address - City:FISHERS
Mailing Address - State:IN
Mailing Address - Zip Code:46038-2532
Mailing Address - Country:US
Mailing Address - Phone:317-308-9616
Mailing Address - Fax:
Practice Address - Street 1:5930 ADOBE RD
Practice Address - Street 2:
Practice Address - City:TWENTYNINE PALMS
Practice Address - State:CA
Practice Address - Zip Code:92277-2356
Practice Address - Country:US
Practice Address - Phone:760-367-1743
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-25
Last Update Date:2019-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT296699225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist