Provider Demographics
NPI:1215410253
Name:HONAHAN, JORDAN TAYLOR (DPT)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:TAYLOR
Last Name:HONAHAN
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:JORDAN
Other - Middle Name:TAYLOR
Other - Last Name:CONROY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:435 HARTFORD TPKE STE U
Mailing Address - Street 2:
Mailing Address - City:VERNON
Mailing Address - State:CT
Mailing Address - Zip Code:06066-4834
Mailing Address - Country:US
Mailing Address - Phone:860-979-1611
Mailing Address - Fax:
Practice Address - Street 1:586 MIDDLE TPKE E
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06040-3730
Practice Address - Country:US
Practice Address - Phone:860-645-3810
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-14
Last Update Date:2019-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT012022225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT012022OtherCT LICENSE