Basic Information
| Provider Information | |||||||||
| NPI: | 1770989204 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WEISE | ||||||||
| FirstName: | JORDON | ||||||||
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| Credential: | LAT,ATC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8823 PRODUCTION LN | ||||||||
| Address2: | |||||||||
| City: | OOLTEWAH | ||||||||
| State: | TN | ||||||||
| PostalCode: | 373636511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4232387217 | ||||||||
| FaxNumber: | 4232856647 | ||||||||
| Practice Location | |||||||||
| Address1: | 878 HIGHWAY 411 N | ||||||||
| Address2: | |||||||||
| City: | ETOWAH | ||||||||
| State: | TN | ||||||||
| PostalCode: | 373311912 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4232637070 | ||||||||
| FaxNumber: | 4232637077 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/11/2014 | ||||||||
| LastUpdateDate: | 08/07/2015 | ||||||||
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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 | 1926 | TN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer |
No ID Information.