Provider Demographics
NPI:1649750662
Name:JORDAN, DAVID RAYMOND (PTA)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:RAYMOND
Last Name:JORDAN
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 GLENWOOD PL
Mailing Address - Street 2:
Mailing Address - City:SILOAM SPRINGS
Mailing Address - State:AR
Mailing Address - Zip Code:72761-2317
Mailing Address - Country:US
Mailing Address - Phone:479-215-9082
Mailing Address - Fax:
Practice Address - Street 1:301 GLENWOOD PL
Practice Address - Street 2:
Practice Address - City:SILOAM SPRINGS
Practice Address - State:AR
Practice Address - Zip Code:72761
Practice Address - Country:US
Practice Address - Phone:479-215-9082
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-20
Last Update Date:2018-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR4387225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant