Provider Demographics
NPI:1245795715
Name:HARRELL, JORDAN RAE
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:RAE
Last Name:HARRELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1135 BARCLAY CIR SE APT 331B
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-2901
Mailing Address - Country:US
Mailing Address - Phone:919-438-8840
Mailing Address - Fax:
Practice Address - Street 1:1135 BARCLAY CIR SE APT 331B
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-2901
Practice Address - Country:US
Practice Address - Phone:919-438-8840
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-08
Last Update Date:2019-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer