Provider Demographics
NPI:1083991558
Name:MOEN, JORDAN J (DPT, OCS)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:J
Last Name:MOEN
Suffix:
Gender:M
Credentials:DPT, OCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 MADISON AVE STE 100AA
Mailing Address - Street 2:
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56001-5465
Mailing Address - Country:US
Mailing Address - Phone:507-385-2600
Mailing Address - Fax:
Practice Address - Street 1:1400 MADISON AVE STE 100AA
Practice Address - Street 2:
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-5465
Practice Address - Country:US
Practice Address - Phone:507-385-2600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-10
Last Update Date:2021-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN8819225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist