Basic Information
Provider Information | |||||||||
NPI: | 1760066229 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GASTON | ||||||||
FirstName: | JORDAN | ||||||||
MiddleName: | PAUL | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 168 | ||||||||
Address2: |   | ||||||||
City: | CRYSTAL SPRINGS | ||||||||
State: | MS | ||||||||
PostalCode: | 390590168 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8505889641 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1482 CHANNING DR | ||||||||
Address2: |   | ||||||||
City: | THOMPSONS STATION | ||||||||
State: | TN | ||||||||
PostalCode: | 371792900 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3186130294 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/11/2021 | ||||||||
LastUpdateDate: | 05/11/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/11/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PTH10120 | AL | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
ID Information
ID | Type | State | Issuer | Description | PTH10120 | 01 | AL | ALABAMA PT BOARD | OTHER |