Provider Demographics
NPI:1689191694
Name:MAEDA, JORDAN BETH (DPT)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:BETH
Last Name:MAEDA
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:JORDON
Other - Middle Name:BETH
Other - Last Name:DAVIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:199 N BROOKMOORE DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:MS
Mailing Address - Zip Code:39705-2024
Mailing Address - Country:US
Mailing Address - Phone:662-327-6705
Mailing Address - Fax:662-327-6760
Practice Address - Street 1:7213 S SIWELL RD STE A
Practice Address - Street 2:
Practice Address - City:BYRAM
Practice Address - State:MS
Practice Address - Zip Code:39272-9776
Practice Address - Country:US
Practice Address - Phone:601-346-9191
Practice Address - Fax:601-346-5011
Is Sole Proprietor?:No
Enumeration Date:2017-08-30
Last Update Date:2018-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
MSPT6570225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist