Provider Demographics
NPI:1780034066
Name:JORDAN, MICHAEL CHRISTOPHER (LAT ATC)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:CHRISTOPHER
Last Name:JORDAN
Suffix:
Gender:M
Credentials:LAT ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5122 BLACKSTONE LN
Mailing Address - Street 2:
Mailing Address - City:NORTHPORT
Mailing Address - State:AL
Mailing Address - Zip Code:35473-1092
Mailing Address - Country:US
Mailing Address - Phone:205-603-9961
Mailing Address - Fax:205-333-4776
Practice Address - Street 1:1325 MCFARLAND BLVD
Practice Address - Street 2:
Practice Address - City:NORTHPORT
Practice Address - State:AL
Practice Address - Zip Code:35476-3270
Practice Address - Country:US
Practice Address - Phone:205-333-4766
Practice Address - Fax:205-333-4776
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-16
Last Update Date:2016-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL12452255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL1245OtherALABAMA BOARD OF ATHLETIC TRAINERS