Provider Demographics
NPI:1467013748
Name:MAGRUDER, JORDAN PAGE
Entity Type:Individual
Prefix:MISS
First Name:JORDAN
Middle Name:PAGE
Last Name:MAGRUDER
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:PO BOX 515
Mailing Address - Street 2:
Mailing Address - City:RUSK
Mailing Address - State:TX
Mailing Address - Zip Code:75785-0515
Mailing Address - Country:US
Mailing Address - Phone:903-279-6683
Mailing Address - Fax:
Practice Address - Street 1:100 E FERGUSON ST
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75702-5759
Practice Address - Country:US
Practice Address - Phone:903-509-2040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-26
Last Update Date:2019-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX115712235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist