Provider Demographics
NPI:1447776117
Name:GALLOWAY, JORDAN HALEY
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:HALEY
Last Name:GALLOWAY
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 1:921 KIRBY FARM DR
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29506-8901
Mailing Address - Country:US
Mailing Address - Phone:843-496-9146
Mailing Address - Fax:
Practice Address - Street 1:719 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:SC
Practice Address - Zip Code:29571-2517
Practice Address - Country:US
Practice Address - Phone:843-423-1811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-15
Last Update Date:2017-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3737224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant