Provider Demographics
NPI:1366726861
Name:JORDAN, PHILIP RUSSELL (DC)
Entity type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:RUSSELL
Last Name:JORDAN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2741 WHISKEY RD
Mailing Address - Street 2:
Mailing Address - City:AIKEN
Mailing Address - State:SC
Mailing Address - Zip Code:29803-6197
Mailing Address - Country:US
Mailing Address - Phone:803-226-0217
Mailing Address - Fax:803-226-0459
Practice Address - Street 1:2741 WHISKEY RD
Practice Address - Street 2:
Practice Address - City:AIKEN
Practice Address - State:SC
Practice Address - Zip Code:29803-6197
Practice Address - Country:US
Practice Address - Phone:803-226-0217
Practice Address - Fax:803-226-0459
Is Sole Proprietor?:No
Enumeration Date:2011-10-03
Last Update Date:2013-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3663111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor