Provider Demographics
NPI:1699030262
Name:SHETTLE, JORDAN ADAM (DPT)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:ADAM
Last Name:SHETTLE
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6221 GREENLEIGH AVE
Mailing Address - Street 2:UNIT 515
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21220-2038
Mailing Address - Country:US
Mailing Address - Phone:717-817-4308
Mailing Address - Fax:
Practice Address - Street 1:8303 PULASKI HWY
Practice Address - Street 2:STE A
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21237-2962
Practice Address - Country:US
Practice Address - Phone:443-372-5300
Practice Address - Fax:443-372-5810
Is Sole Proprietor?:No
Enumeration Date:2012-07-10
Last Update Date:2019-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD24870225100000X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist