Provider Demographics
NPI:1689148439
Name:OUTWATER, JORDAN I
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:I
Last Name:OUTWATER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:49 LINDBERGH PL
Mailing Address - Street 2:
Mailing Address - City:POUGHKEEPSIE
Mailing Address - State:NY
Mailing Address - Zip Code:12603-1335
Mailing Address - Country:US
Mailing Address - Phone:845-380-1812
Mailing Address - Fax:
Practice Address - Street 1:49 LINDBERGH PL
Practice Address - Street 2:
Practice Address - City:POUGHKEEPSIE
Practice Address - State:NY
Practice Address - Zip Code:12603-1335
Practice Address - Country:US
Practice Address - Phone:845-380-1812
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-15
Last Update Date:2019-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer