Provider Demographics
NPI:1285267203
Name:PICKENS, JORDAN W
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:W
Last Name:PICKENS
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 1:2933 FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND
Mailing Address - State:IN
Mailing Address - Zip Code:46322-1637
Mailing Address - Country:US
Mailing Address - Phone:219-678-1255
Mailing Address - Fax:
Practice Address - Street 1:2933 FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:HIGHLAND
Practice Address - State:IN
Practice Address - Zip Code:46322-1637
Practice Address - Country:US
Practice Address - Phone:219-678-1255
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-18
Last Update Date:2020-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant