Provider Demographics
NPI:1336787670
Name:SHORT, JORDAN LEWIS
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:LEWIS
Last Name:SHORT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5061 CLEMENT AVE
Mailing Address - Street 2:
Mailing Address - City:MAPLE HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44137-1317
Mailing Address - Country:US
Mailing Address - Phone:216-571-1079
Mailing Address - Fax:
Practice Address - Street 1:5061 CLEMENT AVE
Practice Address - Street 2:
Practice Address - City:MAPLE HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44137-1317
Practice Address - Country:US
Practice Address - Phone:216-571-1079
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-17
Last Update Date:2019-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer