Provider Demographics
NPI:1881493641
Name:RADEBAUGH, JORDAN (PT, DPT)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:RADEBAUGH
Suffix:
Gender:
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2411 TONY TANK LN APT 208
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27613-3860
Mailing Address - Country:US
Mailing Address - Phone:720-339-0512
Mailing Address - Fax:
Practice Address - Street 1:4109 WAKE FOREST RD STE 200
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-6262
Practice Address - Country:US
Practice Address - Phone:919-322-0042
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-12
Last Update Date:2025-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP23852225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist