Provider Demographics
NPI:1598431603
Name:EAGLESON, JORDAN KAIT (LPTA)
Entity type:Individual
Prefix:MRS
First Name:JORDAN
Middle Name:KAIT
Last Name:EAGLESON
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10755 GLENAYR DR
Mailing Address - Street 2:
Mailing Address - City:CAMBY
Mailing Address - State:IN
Mailing Address - Zip Code:46113-8908
Mailing Address - Country:US
Mailing Address - Phone:618-204-9405
Mailing Address - Fax:
Practice Address - Street 1:4851 TINCHER RD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46221-3780
Practice Address - Country:US
Practice Address - Phone:317-856-4851
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-18
Last Update Date:2024-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06006029A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant