Provider Demographics
NPI:1689448771
Name:RUDD, JORDAN NICOLE
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:NICOLE
Last Name:RUDD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 ROSE CORAL WAY
Mailing Address - Street 2:
Mailing Address - City:DUNCAN
Mailing Address - State:SC
Mailing Address - Zip Code:29334-8894
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1400 WHEAT ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29208-4112
Practice Address - Country:US
Practice Address - Phone:803-777-5261
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-09
Last Update Date:2023-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer