Provider Demographics
NPI:1952321184
Name:JORDAN, GERALD STEPHEN JR (ATC)
Entity Type:Individual
Prefix:MR
First Name:GERALD
Middle Name:STEPHEN
Last Name:JORDAN
Suffix:JR
Gender:M
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:DSU PO BOX 683
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:MS
Mailing Address - Zip Code:38733-0001
Mailing Address - Country:US
Mailing Address - Phone:662-846-4300
Mailing Address - Fax:662-846-4297
Practice Address - Street 1:1417 MAPLE ST
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:MS
Practice Address - Zip Code:38733-0001
Practice Address - Country:US
Practice Address - Phone:662-846-4300
Practice Address - Fax:662-846-4297
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSAT03282255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer