Provider Demographics
NPI:1447607528
Name:MOSES, JORDAN (ATC, CSCS, USAW)
Entity type:Individual
Prefix:MR
First Name:JORDAN
Middle Name:
Last Name:MOSES
Suffix:
Gender:M
Credentials:ATC, CSCS, USAW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 LAKEWOOD DR
Mailing Address - Street 2:APT S4
Mailing Address - City:PHENIX CITY
Mailing Address - State:AL
Mailing Address - Zip Code:36867-1867
Mailing Address - Country:US
Mailing Address - Phone:812-760-9985
Mailing Address - Fax:
Practice Address - Street 1:1800 LAKEWOOD DR
Practice Address - Street 2:APT S4
Practice Address - City:PHENIX CITY
Practice Address - State:AL
Practice Address - Zip Code:36867-1867
Practice Address - Country:US
Practice Address - Phone:812-760-9985
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-19
Last Update Date:2016-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAT0028932083S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083S0010XAllopathic & Osteopathic PhysiciansPreventive MedicineSports Medicine