Provider Demographics
NPI:1184085763
Name:JORDAN, HOLLY (PTA)
Entity type:Individual
Prefix:
First Name:HOLLY
Middle Name:
Last Name:JORDAN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:129 COMMERCIAL DR UNIT 5B
Mailing Address - Street 2:
Mailing Address - City:YORKVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60560-4731
Mailing Address - Country:US
Mailing Address - Phone:630-553-7737
Mailing Address - Fax:630-553-7747
Practice Address - Street 1:129 COMMERCIAL DR UNIT 5B
Practice Address - Street 2:
Practice Address - City:YORKVILLE
Practice Address - State:IL
Practice Address - Zip Code:60560-4731
Practice Address - Country:US
Practice Address - Phone:630-553-7737
Practice Address - Fax:630-553-7747
Is Sole Proprietor?:No
Enumeration Date:2016-03-10
Last Update Date:2016-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160007427225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL160007427OtherIL LICENSE