Provider Demographics
NPI:1649772955
Name:MATTHEW, JORDAN RAE (DC)
Entity type:Individual
Prefix:DR
First Name:JORDAN
Middle Name:RAE
Last Name:MATTHEW
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:JORDAN
Other - Middle Name:RAE
Other - Last Name:LOCKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4021 N ARMENIA AVE STE 103
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33607-1010
Mailing Address - Country:US
Mailing Address - Phone:813-724-3791
Mailing Address - Fax:813-804-4163
Practice Address - Street 1:4021 N ARMENIA AVE STE 103
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607-1010
Practice Address - Country:US
Practice Address - Phone:813-724-3791
Practice Address - Fax:813-804-4163
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-02
Last Update Date:2022-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018000022111N00000X
FL12429111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor