Provider Demographics
NPI:1902860794
Name:JORDAN, AMY B (ATC, LAT)
Entity Type:Individual
Prefix:MRS
First Name:AMY
Middle Name:B
Last Name:JORDAN
Suffix:
Gender:F
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2229 BETHANY LN
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:OH
Mailing Address - Zip Code:43302-8365
Mailing Address - Country:US
Mailing Address - Phone:419-496-3769
Mailing Address - Fax:
Practice Address - Street 1:2525 W 4TH ST
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44906-1208
Practice Address - Country:US
Practice Address - Phone:419-755-5109
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAT-1591174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist