Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208100000X | Physical Medicine & Rehabilitation Doctor | 30164 | NE |
NPI | 1033572821 |
---|---|
Provider Name | Dr. Jordan Evan Brennon Powell |
First Address | Fort Sam Houston, TX 78234-4504 |
Second Address | Fort Sam Houston, TX 78234-4504 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 30/03/2016 |
Last Update Date | 02/07/2020 |