Provider Demographics
NPI:1992367163
Name:POWELL, JORDAN
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:POWELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4050 E COTTON CENTER BLVD STE 18
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85040-8862
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1745 W HUNT HWY # B-103
Practice Address - Street 2:
Practice Address - City:SAN TAN VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85143-5215
Practice Address - Country:US
Practice Address - Phone:480-568-4580
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-08
Last Update Date:2019-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ30725225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist