Provider Demographics
NPI:1841784170
Name:BETTLEYON, JORDAN DREW (MS, LAT, ATC, EP-C)
Entity Type:Individual
Prefix:MR
First Name:JORDAN
Middle Name:DREW
Last Name:BETTLEYON
Suffix:
Gender:M
Credentials:MS, LAT, ATC, EP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:408 TARTAN CT
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28311-1694
Mailing Address - Country:US
Mailing Address - Phone:570-274-6387
Mailing Address - Fax:
Practice Address - Street 1:5400 RAMSEY ST
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28311
Practice Address - Country:US
Practice Address - Phone:910-630-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-20
Last Update Date:2018-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARTO0003112081S0010X
NY0035972081S0010X
NC39942081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine