Provider Demographics
NPI:1912486101
Name:LENNON, JORDAN C
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:C
Last Name:LENNON
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 1:940 DAVIS ST N
Mailing Address - Street 2:
Mailing Address - City:SULPHUR SPRINGS
Mailing Address - State:TX
Mailing Address - Zip Code:75482-5428
Mailing Address - Country:US
Mailing Address - Phone:903-348-0605
Mailing Address - Fax:
Practice Address - Street 1:940 DAVIS ST N
Practice Address - Street 2:
Practice Address - City:SULPHUR SPRINGS
Practice Address - State:TX
Practice Address - Zip Code:75482-5428
Practice Address - Country:US
Practice Address - Phone:903-348-0605
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-09
Last Update Date:2018-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2123001225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant