Provider Demographics
NPI:1366169971
Name:BEVINS, JORDAN M (PT, DPT)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:M
Last Name:BEVINS
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 1:711 W WENGER RD APT 205
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:45322-1920
Mailing Address - Country:US
Mailing Address - Phone:937-670-6922
Mailing Address - Fax:
Practice Address - Street 1:711 W WENGER RD APT 205
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:OH
Practice Address - Zip Code:45322-1920
Practice Address - Country:US
Practice Address - Phone:937-670-6922
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-24
Last Update Date:2022-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT018971225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist