Provider Demographics
NPI:1477967867
Name:BREWER, JORDAN (DPT)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:BREWER
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:339 RACETRACK RD NW
Mailing Address - Street 2:STE 20
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32547-1581
Mailing Address - Country:US
Mailing Address - Phone:334-625-5795
Mailing Address - Fax:
Practice Address - Street 1:16201 PANAMA CITY BEACH PKWY
Practice Address - Street 2:SUITE A
Practice Address - City:PANAMA CITY BEACH
Practice Address - State:FL
Practice Address - Zip Code:32413-5306
Practice Address - Country:US
Practice Address - Phone:850-250-0826
Practice Address - Fax:850-250-0840
Is Sole Proprietor?:No
Enumeration Date:2014-06-13
Last Update Date:2020-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT27428225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL12734214OtherCAQH
FLY0N0EOtherFLORIDA BLUE
FL12734214OtherCAQH
FLHW217YMedicare PIN