Provider Demographics
NPI:1568845139
Name:PROFITT, JORDAN (MA, ATC/L)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:PROFITT
Suffix:
Gender:M
Credentials:MA, ATC/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17927 26TH STREET CT E
Mailing Address - Street 2:
Mailing Address - City:LAKE TAPPS
Mailing Address - State:WA
Mailing Address - Zip Code:98391-9408
Mailing Address - Country:US
Mailing Address - Phone:253-332-3398
Mailing Address - Fax:
Practice Address - Street 1:607 DEWEY AVE NW STE 300
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49504-7335
Practice Address - Country:US
Practice Address - Phone:253-332-3398
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-01
Last Update Date:2015-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAA160577346174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist