Provider Demographics
NPI:1134435852
Name:LEEP, JORDAN PAUL (ATC, LAT)
Entity type:Individual
Prefix:MR
First Name:JORDAN
Middle Name:PAUL
Last Name:LEEP
Suffix:
Gender:M
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 1:1825 S 5TH ST
Mailing Address - Street 2:APT 22
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76706-2409
Mailing Address - Country:US
Mailing Address - Phone:937-215-0236
Mailing Address - Fax:
Practice Address - Street 1:1500 S UNIVERSITY PARKS DR
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76706-1211
Practice Address - Country:US
Practice Address - Phone:254-710-1021
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-19
Last Update Date:2010-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
2000004553OtherNATABOC