Provider Demographics
NPI:1437191160
Name:JORDAN, CAROL A (PT)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:A
Last Name:JORDAN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:CAROL
Other - Middle Name:A
Other - Last Name:JORDAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:355 HIGHWAY 111
Mailing Address - Street 2:
Mailing Address - City:ALADDIN
Mailing Address - State:WY
Mailing Address - Zip Code:82710-9715
Mailing Address - Country:US
Mailing Address - Phone:307-290-2447
Mailing Address - Fax:
Practice Address - Street 1:113 COMANCHE RD
Practice Address - Street 2:
Practice Address - City:FORT MEADE
Practice Address - State:SD
Practice Address - Zip Code:57741-1002
Practice Address - Country:US
Practice Address - Phone:605-347-2511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-10
Last Update Date:2014-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYPT-1225225100000X
NE1498225100000X
SD0917225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist