Provider Demographics
NPI:1598155897
Name:JORDAN, DIAMOND (PTA)
Entity Type:Individual
Prefix:
First Name:DIAMOND
Middle Name:
Last Name:JORDAN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6675 LAKE ISLAND DR
Mailing Address - Street 2:
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33467-7905
Mailing Address - Country:US
Mailing Address - Phone:205-799-1278
Mailing Address - Fax:
Practice Address - Street 1:8993 OKEECHOBEE BLVD
Practice Address - Street 2:STE 100
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33411-5144
Practice Address - Country:US
Practice Address - Phone:561-478-3702
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-26
Last Update Date:2015-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL25497225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant