Provider Demographics
NPI:1780041442
Name:RICHMOND, JORDAN GRACE (ATC)
Entity Type:Individual
Prefix:MISS
First Name:JORDAN
Middle Name:GRACE
Last Name:RICHMOND
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:651 E FOOTHILL BLVD
Mailing Address - Street 2:
Mailing Address - City:GLENDORA
Mailing Address - State:CA
Mailing Address - Zip Code:91741-2713
Mailing Address - Country:US
Mailing Address - Phone:909-731-5934
Mailing Address - Fax:
Practice Address - Street 1:651 E FOOTHILL BLVD
Practice Address - Street 2:
Practice Address - City:GLENDORA
Practice Address - State:CA
Practice Address - Zip Code:91741-2713
Practice Address - Country:US
Practice Address - Phone:909-731-5934
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-26
Last Update Date:2016-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ15102255A2300X
CA2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer