Provider Demographics
NPI:1255828554
Name:GALENTINE, JORDAN DAVID (PTA)
Entity Type:Individual
Prefix:MR
First Name:JORDAN
Middle Name:DAVID
Last Name:GALENTINE
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4754 MARTIN RD STE 200
Mailing Address - Street 2:
Mailing Address - City:FLOWERY BRANCH
Mailing Address - State:GA
Mailing Address - Zip Code:30542-3507
Mailing Address - Country:US
Mailing Address - Phone:770-967-4377
Mailing Address - Fax:770-967-8077
Practice Address - Street 1:4754 MARTIN RD STE 200
Practice Address - Street 2:
Practice Address - City:FLOWERY BRANCH
Practice Address - State:GA
Practice Address - Zip Code:30542-3507
Practice Address - Country:US
Practice Address - Phone:770-967-4377
Practice Address - Fax:770-967-8077
Is Sole Proprietor?:No
Enumeration Date:2018-04-23
Last Update Date:2018-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPTA003970225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant