Provider Demographics
NPI:1629680657
Name:DEHARTY, JORDAN K (LMT)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:K
Last Name:DEHARTY
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:333 SW 5TH ST
Mailing Address - Street 2:
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97526-2509
Mailing Address - Country:US
Mailing Address - Phone:541-507-9894
Mailing Address - Fax:
Practice Address - Street 1:333 SW 5TH ST
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97526-2509
Practice Address - Country:US
Practice Address - Phone:541-507-9894
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-20
Last Update Date:2020-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR21792225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist