Provider Demographics
NPI:1760066229
Name:GASTON, JORDAN PAUL
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:PAUL
Last Name:GASTON
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:PO BOX 168
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:39059-0168
Mailing Address - Country:US
Mailing Address - Phone:850-588-9641
Mailing Address - Fax:
Practice Address - Street 1:1482 CHANNING DR
Practice Address - Street 2:
Practice Address - City:THOMPSONS STATION
Practice Address - State:TN
Practice Address - Zip Code:37179-2900
Practice Address - Country:US
Practice Address - Phone:318-613-0294
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-11
Last Update Date:2021-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPTH10120225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALPTH10120OtherALABAMA PT BOARD