Provider Demographics
NPI:1235589680
Name:OLSON, JORDAN (ATC)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:OLSON
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:JORDAN
Other - Middle Name:
Other - Last Name:HEFFERNAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ATC
Mailing Address - Street 1:1662 RUGBY AVE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30337-2116
Mailing Address - Country:US
Mailing Address - Phone:404-765-4062
Mailing Address - Fax:
Practice Address - Street 1:1662 RUGBY AVE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30337-2116
Practice Address - Country:US
Practice Address - Phone:404-765-4062
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-16
Last Update Date:2019-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL34782255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer