Basic Information
| Provider Information | |||||||||
| NPI: | 1689191694 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MAEDA | ||||||||
| FirstName: | JORDAN | ||||||||
| MiddleName: | BETH | ||||||||
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| Credential: | DPT | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | DAVIS | ||||||||
| OtherFirstName: | JORDON | ||||||||
| OtherMiddleName: | BETH | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 199 N BROOKMOORE DR | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | MS | ||||||||
| PostalCode: | 397052024 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6623276705 | ||||||||
| FaxNumber: | 6623276760 | ||||||||
| Practice Location | |||||||||
| Address1: | 7213 S SIWELL RD STE A | ||||||||
| Address2: | |||||||||
| City: | BYRAM | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392729776 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6013469191 | ||||||||
| FaxNumber: | 6013465011 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2017 | ||||||||
| LastUpdateDate: | 10/04/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | PT6570 | MS | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.