Provider Demographics
NPI:1992402754
Name:HAIRSTON, JORDAN RUSSELL (PT, DPT)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:RUSSELL
Last Name:HAIRSTON
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1212 BATH AVE STE 350
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:KY
Mailing Address - Zip Code:41101-3685
Mailing Address - Country:US
Mailing Address - Phone:606-324-0540
Mailing Address - Fax:606-324-0616
Practice Address - Street 1:711 S 3RD ST
Practice Address - Street 2:
Practice Address - City:IRONTON
Practice Address - State:OH
Practice Address - Zip Code:45638-1854
Practice Address - Country:US
Practice Address - Phone:740-534-1156
Practice Address - Fax:606-324-0616
Is Sole Proprietor?:No
Enumeration Date:2023-02-13
Last Update Date:2023-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT020276225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist