Provider Demographics
NPI:1215586052
Name:JORDAN, AUTUMN (ATC)
Entity Type:Individual
Prefix:
First Name:AUTUMN
Middle Name:
Last Name:JORDAN
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 73
Mailing Address - Street 2:
Mailing Address - City:FORT LAWN
Mailing Address - State:SC
Mailing Address - Zip Code:29714-0073
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3971 LEWISVILLE HIGH SCHOOL RD
Practice Address - Street 2:
Practice Address - City:RICHBURG
Practice Address - State:SC
Practice Address - Zip Code:29729-9029
Practice Address - Country:US
Practice Address - Phone:803-246-9969
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-04
Last Update Date:2019-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer