Provider Demographics
NPI:1194069237
Name:JORDAN, LISA (DPT)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:JORDAN
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:JORDAN
Other - Last Name:LEE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:630-296-2223
Mailing Address - Fax:630-759-9510
Practice Address - Street 1:6842 RACE TRACK RD
Practice Address - Street 2:
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20715-3011
Practice Address - Country:US
Practice Address - Phone:240-544-0200
Practice Address - Fax:301-464-1053
Is Sole Proprietor?:No
Enumeration Date:2012-11-15
Last Update Date:2017-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEJ1-0002908225100000X
MD24299225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist