Provider Demographics
NPI:1265965479
Name:CANTU, JORDAN
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:CANTU
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 FESPERMAN CIR
Mailing Address - Street 2:
Mailing Address - City:TROUTMAN
Mailing Address - State:NC
Mailing Address - Zip Code:28166-7754
Mailing Address - Country:US
Mailing Address - Phone:845-662-2733
Mailing Address - Fax:
Practice Address - Street 1:752 E CENTER AVE
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28115-2591
Practice Address - Country:US
Practice Address - Phone:704-663-3448
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-05
Last Update Date:2017-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA5519225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant