Provider Demographics
NPI:1225393903
Name:PAUTLER, JORDAN NICOLE (PTA)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:NICOLE
Last Name:PAUTLER
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2011 CORONA RD
Mailing Address - Street 2:SUITE 301
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65203-2548
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2011 CORONA RD
Practice Address - Street 2:SUITE 301
Practice Address - City:COLUMBIA
Practice Address - State:MISSOURI
Practice Address - Zip Code:65203
Practice Address - Country:UM
Practice Address - Phone:314-543-3860
Practice Address - Fax:314-272-0343
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-10
Last Update Date:2012-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012022170225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant