Provider Demographics
NPI:1174088637
Name:STUCKEY, JORDAN SYMONE
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:SYMONE
Last Name:STUCKEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2836 PAM PL
Mailing Address - Street 2:
Mailing Address - City:REX
Mailing Address - State:GA
Mailing Address - Zip Code:30273-2337
Mailing Address - Country:US
Mailing Address - Phone:678-510-8837
Mailing Address - Fax:
Practice Address - Street 1:2836 PAM PL
Practice Address - Street 2:
Practice Address - City:REX
Practice Address - State:GA
Practice Address - Zip Code:30273-2337
Practice Address - Country:US
Practice Address - Phone:678-510-8837
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-08
Last Update Date:2019-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer