Provider Demographics
NPI:1215592647
Name:CARPENTER, JORDAN LEIGH (PT)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:LEIGH
Last Name:CARPENTER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:JORDAN
Other - Middle Name:LEIGH
Other - Last Name:TRIMM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:921 W. BEACON ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:MS
Mailing Address - Zip Code:39350-3229
Mailing Address - Country:US
Mailing Address - Phone:601-650-0002
Mailing Address - Fax:601-650-9902
Practice Address - Street 1:7 RIVERS DR
Practice Address - Street 2:SUITE 10 & 20
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39401-1324
Practice Address - Country:US
Practice Address - Phone:601-909-5006
Practice Address - Fax:601-909-5008
Is Sole Proprietor?:No
Enumeration Date:2019-05-01
Last Update Date:2024-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MSPT7771225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program