1699221804 NPI number — JORDAN THRASHER WILKINS PT, DPT

Table of content: JORDAN THRASHER WILKINS PT, DPT (NPI 1699221804)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699221804 NPI number — JORDAN THRASHER WILKINS PT, DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILKINS
Provider First Name:
JORDAN
Provider Middle Name:
THRASHER
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT, DPT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
THRASHER
Provider Other First Name:
JORDAN
Provider Other Middle Name:
KATE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PT, DPT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1699221804
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/26/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6397 LEE HWY STE 300
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHATTANOOGA
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37421-4915
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-238-7217
Provider Business Mailing Address Fax Number:
423-238-3473

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
119 CANAL ST STE 104
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
POOLER
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31322-4094
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
912-330-8444
Provider Business Practice Location Address Fax Number:
912-330-8844
Provider Enumeration Date:
08/28/2016

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  PT012529 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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