Provider Demographics
NPI:1194131870
Name:BENNETT, JORDAN
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:BENNETT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11010 DAVID ST STE A
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39503-3481
Mailing Address - Country:US
Mailing Address - Phone:228-832-8327
Mailing Address - Fax:
Practice Address - Street 1:11010 DAVID ST STE A
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-3481
Practice Address - Country:US
Practice Address - Phone:228-832-8327
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-02
Last Update Date:2023-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT5517225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist