Provider Demographics
NPI:1508381278
Name:TAIT, JORDAN (DPT)
Entity Type:Individual
Prefix:MR
First Name:JORDAN
Middle Name:
Last Name:TAIT
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 1:5800 FAIRFIELD AVE STE 150
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46807-3450
Mailing Address - Country:US
Mailing Address - Phone:260-744-5585
Mailing Address - Fax:
Practice Address - Street 1:5800 FAIRFIELD AVE STE 150
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46807-3450
Practice Address - Country:US
Practice Address - Phone:260-744-5585
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-03
Last Update Date:2017-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05012567A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist