Provider Demographics
NPI:1053945832
Name:JORDAN, ELLIE (ATC, LAT)
Entity type:Individual
Prefix:
First Name:ELLIE
Middle Name:
Last Name:JORDAN
Suffix:
Gender:F
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8052 POWELLS CHAPEL ROAD
Mailing Address - Street 2:
Mailing Address - City:MURFREESBORO
Mailing Address - State:TN
Mailing Address - Zip Code:37129-8420
Mailing Address - Country:US
Mailing Address - Phone:615-568-8644
Mailing Address - Fax:
Practice Address - Street 1:1322 N RUTHERFORD BLVD APT C18
Practice Address - Street 2:
Practice Address - City:MURFREESBORO
Practice Address - State:TN
Practice Address - Zip Code:37130-8420
Practice Address - Country:US
Practice Address - Phone:615-568-8644
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-02
Last Update Date:2022-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN27972255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer