Provider Demographics
NPI:1457730335
Name:PRIEBE, JORDAN DAVID (PTA)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:DAVID
Last Name:PRIEBE
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16744 CAGAN CROSSINGS BLVD
Mailing Address - Street 2:APT. 7
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34714-4886
Mailing Address - Country:US
Mailing Address - Phone:321-439-1356
Mailing Address - Fax:
Practice Address - Street 1:5245 N SOCRUM LOOP RD
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33809-4253
Practice Address - Country:US
Practice Address - Phone:863-859-1446
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-25
Last Update Date:2015-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL25673225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant