Provider Demographics
NPI:1801443767
Name:PRIDGIN, JORDAN MICHAEL (DPT)
Entity type:Individual
Prefix:DR
First Name:JORDAN
Middle Name:MICHAEL
Last Name:PRIDGIN
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1506 W 3RD ST
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72801-4828
Mailing Address - Country:US
Mailing Address - Phone:479-857-3983
Mailing Address - Fax:
Practice Address - Street 1:8952 MARKET ST # 7B
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:AR
Practice Address - Zip Code:72837-9110
Practice Address - Country:US
Practice Address - Phone:479-331-3303
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-23
Last Update Date:2019-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPT4226225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist