Provider Demographics
NPI:1366503518
Name:JORDAN, TRACY W (LPT)
Entity Type:Individual
Prefix:MR
First Name:TRACY
Middle Name:W
Last Name:JORDAN
Suffix:
Gender:M
Credentials:LPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1668 NC HWY 16 SOUTH
Mailing Address - Street 2:
Mailing Address - City:TAYLORSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28681
Mailing Address - Country:US
Mailing Address - Phone:828-632-9736
Mailing Address - Fax:828-632-9544
Practice Address - Street 1:1668 NC HIGHWAY 16 S
Practice Address - Street 2:
Practice Address - City:TAYLORSVILLE
Practice Address - State:NC
Practice Address - Zip Code:28681-6285
Practice Address - Country:US
Practice Address - Phone:828-632-9736
Practice Address - Fax:828-632-9544
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCNC6896225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCNC6896OtherLICENSE #
NC078VAOtherBCBS PROVIDER #