Provider Demographics
NPI:1215593843
Name:WEAVER, JORDYN (AT, AT-C)
Entity Type:Individual
Prefix:
First Name:JORDYN
Middle Name:
Last Name:WEAVER
Suffix:
Gender:F
Credentials:AT, AT-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2007 MIRACLE MILE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45503-2836
Mailing Address - Country:US
Mailing Address - Phone:937-450-4511
Mailing Address - Fax:
Practice Address - Street 1:2400 MIAMI VALLEY DR # 160
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:45459-4774
Practice Address - Country:US
Practice Address - Phone:937-312-1661
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-20
Last Update Date:2019-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAT0053072255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer