Provider Demographics
NPI:1346250388
Name:BENNERS, JORDAN (PT)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:BENNERS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:JORDAN
Other - Middle Name:
Other - Last Name:BYERLY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:2758 N GALLOWAY AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MESQUITE
Mailing Address - State:TX
Mailing Address - Zip Code:75150-6380
Mailing Address - Country:US
Mailing Address - Phone:972-681-1155
Mailing Address - Fax:972-681-3575
Practice Address - Street 1:2758 N GALLOWAY AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75150-6380
Practice Address - Country:US
Practice Address - Phone:972-681-1155
Practice Address - Fax:972-681-3575
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2009-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1161172225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1161172OtherPHYSICAL THERAPY LICENSE
TX8T8083OtherBCBS
TX8T8083OtherBCBS