Provider Demographics
NPI:1669625273
Name:JENKINS, JORDAN
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:JENKINS
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 1:2801 RICHMOND RD
Mailing Address - Street 2:#315
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75503-2123
Mailing Address - Country:US
Mailing Address - Phone:903-278-7867
Mailing Address - Fax:866-426-1396
Practice Address - Street 1:917 BEVILLE RD
Practice Address - Street 2:SUITE G
Practice Address - City:SOUTH DAYTONA
Practice Address - State:FL
Practice Address - Zip Code:32119-1712
Practice Address - Country:US
Practice Address - Phone:386-756-4395
Practice Address - Fax:866-426-2811
Is Sole Proprietor?:No
Enumeration Date:2008-10-28
Last Update Date:2008-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2033132225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant