Provider Demographics
NPI:1609461854
Name:CHURCH, JORDAN NICOLE (LAT, ATC)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:NICOLE
Last Name:CHURCH
Suffix:
Gender:F
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2260 E UNIVERSITY DR APT 4G
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:AL
Mailing Address - Zip Code:36830-3341
Mailing Address - Country:US
Mailing Address - Phone:734-718-3795
Mailing Address - Fax:
Practice Address - Street 1:188 S DONAHUE DR
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:AL
Practice Address - Zip Code:36849-5513
Practice Address - Country:US
Practice Address - Phone:737-718-3795
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-09
Last Update Date:2021-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL2050207PS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PS0010XAllopathic & Osteopathic PhysiciansEmergency MedicineSports Medicine