Provider Demographics
NPI:1639860380
Name:JORDAN, SIMONE (PTA)
Entity Type:Individual
Prefix:
First Name:SIMONE
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 1:7402 COPPER CV
Mailing Address - Street 2:
Mailing Address - City:CONVERSE
Mailing Address - State:TX
Mailing Address - Zip Code:78109-3922
Mailing Address - Country:US
Mailing Address - Phone:726-223-6409
Mailing Address - Fax:
Practice Address - Street 1:1600 NE INTERSTATE 410 LOOP #105
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78209
Practice Address - Country:US
Practice Address - Phone:888-727-5659
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-15
Last Update Date:2023-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2158685225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant