Provider Demographics
NPI:1063235323
Name:BROWN, JORDAN NYA
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:NYA
Last Name:BROWN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20915 WILDERNESS OAK APT 1311
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78258-2632
Mailing Address - Country:US
Mailing Address - Phone:210-564-4578
Mailing Address - Fax:
Practice Address - Street 1:18470 BLANCO RD STE 109
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78258-4992
Practice Address - Country:US
Practice Address - Phone:210-564-4578
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-05
Last Update Date:2024-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT142668225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist