Basic Information
| Provider Information | |||||||||
| NPI: | 1518496181 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BENFIELD | ||||||||
| FirstName: | JORDAN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | PT, DPT, ATC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 65 HIGHLAND POINTE CIR E | ||||||||
| Address2: | |||||||||
| City: | DAWSONVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 305349417 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 130 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | CLERMONT | ||||||||
| State: | GA | ||||||||
| PostalCode: | 305271804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6786163099 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2017 | ||||||||
| LastUpdateDate: | 06/07/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT012890 | GA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.