Provider Demographics
NPI:1558810499
Name:FOWLER, JORDAN CHANDLER
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:CHANDLER
Last Name:FOWLER
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 1:1924 WHITE MOUNTAIN DR
Mailing Address - Street 2:
Mailing Address - City:CHESTER
Mailing Address - State:VA
Mailing Address - Zip Code:23836-3008
Mailing Address - Country:US
Mailing Address - Phone:804-543-8377
Mailing Address - Fax:
Practice Address - Street 1:1924 WHITE MOUNTAIN DR
Practice Address - Street 2:
Practice Address - City:CHESTER
Practice Address - State:VA
Practice Address - Zip Code:23836-3008
Practice Address - Country:US
Practice Address - Phone:804-543-8377
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-03
Last Update Date:2016-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant