Provider Demographics
NPI:1568928596
Name:SMITH, JORDAN CHRISTOPHER
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:CHRISTOPHER
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 93
Mailing Address - Street 2:
Mailing Address - City:CHARLES CITY
Mailing Address - State:IA
Mailing Address - Zip Code:50616-0093
Mailing Address - Country:US
Mailing Address - Phone:641-715-1230
Mailing Address - Fax:641-715-1231
Practice Address - Street 1:318 N MAIN ST
Practice Address - Street 2:
Practice Address - City:CHARLES CITY
Practice Address - State:IA
Practice Address - Zip Code:50616-2020
Practice Address - Country:US
Practice Address - Phone:641-715-1230
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-14
Last Update Date:2019-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA094118225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist