Provider Demographics
NPI:1942693007
Name:DEVENNEY, JORDAN SAMANTHA (MS, LAT, ATC)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:SAMANTHA
Last Name:DEVENNEY
Suffix:
Gender:F
Credentials:MS, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3101 NEW LONDON CT APT 510
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47909-5312
Mailing Address - Country:US
Mailing Address - Phone:269-718-9333
Mailing Address - Fax:
Practice Address - Street 1:3001 S CREASY LN STE B
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47905-5206
Practice Address - Country:US
Practice Address - Phone:269-718-9333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-13
Last Update Date:2020-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36003182A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer