Provider Demographics
NPI:1639728066
Name:JORDAN, AUDREY (PT, DPT)
Entity Type:Individual
Prefix:
First Name:AUDREY
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 1:379 PINEHAVEN STREET EXT
Mailing Address - Street 2:
Mailing Address - City:LAURENS
Mailing Address - State:SC
Mailing Address - Zip Code:29360-2672
Mailing Address - Country:US
Mailing Address - Phone:864-984-6584
Mailing Address - Fax:864-984-6464
Practice Address - Street 1:379 PINEHAVEN STREET EXT
Practice Address - Street 2:
Practice Address - City:LAURENS
Practice Address - State:SC
Practice Address - Zip Code:29360-2672
Practice Address - Country:US
Practice Address - Phone:864-984-6584
Practice Address - Fax:864-984-6464
Is Sole Proprietor?:No
Enumeration Date:2019-09-09
Last Update Date:2019-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC9852225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC9852OtherSOUTH CAROLINA BOARD OF PHYSICAL THERAPY EXAMINERS