Provider Demographics
NPI:1710522131
Name:EARLYWINE, JORDAN A (DPT)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:A
Last Name:EARLYWINE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:162 BARNWOOD DR
Mailing Address - Street 2:
Mailing Address - City:EDGEWOOD
Mailing Address - State:KY
Mailing Address - Zip Code:41017-2501
Mailing Address - Country:US
Mailing Address - Phone:859-331-4163
Mailing Address - Fax:859-331-4163
Practice Address - Street 1:540 CENTRE VIEW BLVD
Practice Address - Street 2:
Practice Address - City:CRESTVIEW HILLS
Practice Address - State:KY
Practice Address - Zip Code:41017-3400
Practice Address - Country:US
Practice Address - Phone:513-221-1100
Practice Address - Fax:859-341-3913
Is Sole Proprietor?:No
Enumeration Date:2019-11-08
Last Update Date:2020-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY007821225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist