Provider Demographics
NPI:1558739128
Name:DORRIEN, JORDAN (ATC)
Entity Type:Individual
Prefix:MR
First Name:JORDAN
Middle Name:
Last Name:DORRIEN
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 GUNN RD
Mailing Address - Street 2:APT. 1028
Mailing Address - City:CENTERVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31028-8556
Mailing Address - Country:US
Mailing Address - Phone:973-879-5172
Mailing Address - Fax:
Practice Address - Street 1:402 BLUEBIRD BLVD
Practice Address - Street 2:
Practice Address - City:FORT VALLEY
Practice Address - State:GA
Practice Address - Zip Code:31030-5088
Practice Address - Country:US
Practice Address - Phone:478-825-2021
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-12
Last Update Date:2015-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAT0023162255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer