Basic Information
| Provider Information | |||||||||
| NPI: | 1528640422 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JORDAN | ||||||||
| FirstName: | KEELY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1650 N ROBERTS RD NW APT 2113 | ||||||||
| Address2: | |||||||||
| City: | KENNESAW | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301443777 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7314158488 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3540 COBB PKWY NW STE 300 | ||||||||
| Address2: | |||||||||
| City: | ACWORTH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301014179 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6785016300 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/21/2021 | ||||||||
| LastUpdateDate: | 04/21/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/21/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.