Provider Demographics
NPI:1689200917
Name:BYWATERS, JORDAN RASHAN
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:RASHAN
Last Name:BYWATERS
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 1:6160 TUTT BLVD STE 102
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80923-3503
Mailing Address - Country:US
Mailing Address - Phone:719-215-8722
Mailing Address - Fax:
Practice Address - Street 1:6160 TUTT BLVD STE 102
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80923-3503
Practice Address - Country:US
Practice Address - Phone:719-215-8722
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-18
Last Update Date:2020-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COMT.0022011225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist