Basic Information
| Provider Information | |||||||||
| NPI: | 1245693209 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TEBODA | ||||||||
| FirstName: | JORDAN | ||||||||
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| Credential: | ATC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8259 WICKER AVE | ||||||||
| Address2: | |||||||||
| City: | SAINT JOHN | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463738878 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2193656560 | ||||||||
| FaxNumber: | 2193656561 | ||||||||
| Practice Location | |||||||||
| Address1: | 59 EXECUTIVE PARK S | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303292208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4047786330 | ||||||||
| FaxNumber: | 4047786370 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2016 | ||||||||
| LastUpdateDate: | 03/29/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2255A2300X | AT002448 | GA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer |
No ID Information.