Provider Demographics
NPI:1013438209
Name:CORLEY, JORDAN (LAT, ATC)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:CORLEY
Suffix:
Gender:F
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2039 DOWLEN RD APT 2
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77706-3345
Mailing Address - Country:US
Mailing Address - Phone:409-658-5230
Mailing Address - Fax:
Practice Address - Street 1:5250 BAYOU WILLOW DR
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77705-7054
Practice Address - Country:US
Practice Address - Phone:409-658-5230
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-28
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X
TXAT60262255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer