Provider Demographics
NPI:1639572316
Name:JORDAN, AMANDA (PT, DPT)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:JORDAN
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2635 NW ROLLING GREEN DR
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97330-3519
Mailing Address - Country:US
Mailing Address - Phone:541-752-0545
Mailing Address - Fax:
Practice Address - Street 1:2635 NW ROLLING GREEN DR
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330-3519
Practice Address - Country:US
Practice Address - Phone:541-752-0545
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-08
Last Update Date:2022-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT60509091225100000X
2251X0800X
OR60724225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1639572316Medicaid
WAP01461874OtherRR MEDICARE
WAG8934644, G8934645Medicare PIN