Provider Demographics
NPI:1780300863
Name:POWELL, JORDYN (LMT)
Entity type:Individual
Prefix:
First Name:JORDYN
Middle Name:
Last Name:POWELL
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19467 BAKER RD
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97702-7930
Mailing Address - Country:US
Mailing Address - Phone:541-324-4087
Mailing Address - Fax:
Practice Address - Street 1:711 NE IRVING AVE
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-4738
Practice Address - Country:US
Practice Address - Phone:541-388-0496
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-19
Last Update Date:2022-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR26818225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist