Provider Demographics
NPI:1649937368
Name:WEAVER, JORDON WAYNE
Entity type:Individual
Prefix:
First Name:JORDON
Middle Name:WAYNE
Last Name:WEAVER
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 1:686 LYTLE MOUNTAIN RD
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:NC
Mailing Address - Zip Code:28752-8482
Mailing Address - Country:US
Mailing Address - Phone:843-287-2650
Mailing Address - Fax:
Practice Address - Street 1:686 LYTLE MOUNTAIN RD
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:NC
Practice Address - Zip Code:28752-8482
Practice Address - Country:US
Practice Address - Phone:843-287-2650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-17
Last Update Date:2021-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician