Provider Demographics
NPI:1386145415
Name:BERRY, JORDAN (DPT)
Entity type:Individual
Prefix:DR
First Name:JORDAN
Middle Name:
Last Name:BERRY
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:529 W SUMMIT AVE STE 1D
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28203-4400
Mailing Address - Country:US
Mailing Address - Phone:704-228-3825
Mailing Address - Fax:
Practice Address - Street 1:529 W SUMMIT AVE STE 1D
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28203-4400
Practice Address - Country:US
Practice Address - Phone:704-228-3825
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-23
Last Update Date:2020-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT294526208100000X, 225100000X
NCP18636208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT294526OtherDPT