Provider Demographics
NPI:1851984249
Name:COOKSTON, JORDAN DANIEL
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:DANIEL
Last Name:COOKSTON
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 1:8511 THORN GROVE PIKE
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37914-9391
Mailing Address - Country:US
Mailing Address - Phone:256-960-1407
Mailing Address - Fax:
Practice Address - Street 1:731 MIDDLE CREEK RD
Practice Address - Street 2:
Practice Address - City:SEVIERVILLE
Practice Address - State:TN
Practice Address - Zip Code:37862-5016
Practice Address - Country:US
Practice Address - Phone:865-429-6156
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-16
Last Update Date:2021-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN7731225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant