Provider Demographics
NPI:1528569316
Name:JORDAN C BLACK
Entity Type:Organization
Organization Name:JORDAN C BLACK
Other - Org Name:TRISTAR PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JORDAN
Authorized Official - Middle Name:CHASE
Authorized Official - Last Name:BLACK
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT
Authorized Official - Phone:423-317-7772
Mailing Address - Street 1:PO BOX 608
Mailing Address - Street 2:
Mailing Address - City:BEAN STATION
Mailing Address - State:TN
Mailing Address - Zip Code:37708-0608
Mailing Address - Country:US
Mailing Address - Phone:423-317-7772
Mailing Address - Fax:423-317-7773
Practice Address - Street 1:325 W MORRIS BLVD
Practice Address - Street 2:
Practice Address - City:MORRISTOWN
Practice Address - State:TN
Practice Address - Zip Code:37813-2237
Practice Address - Country:US
Practice Address - Phone:423-317-7772
Practice Address - Fax:423-317-7773
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-27
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical TherapyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ038410Medicaid