Provider Demographics
NPI:1093483406
Name:JORDAN, WYATT C (DPT)
Entity Type:Individual
Prefix:
First Name:WYATT
Middle Name:C
Last Name:JORDAN
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:PO BOX 5718
Mailing Address - Street 2:
Mailing Address - City:KALISPELL
Mailing Address - State:MT
Mailing Address - Zip Code:59903-5718
Mailing Address - Country:US
Mailing Address - Phone:406-756-0134
Mailing Address - Fax:406-300-1612
Practice Address - Street 1:200 E IDAHO ST STE A
Practice Address - Street 2:
Practice Address - City:KALISPELL
Practice Address - State:MT
Practice Address - Zip Code:59901-4117
Practice Address - Country:US
Practice Address - Phone:406-257-5610
Practice Address - Fax:406-257-1372
Is Sole Proprietor?:No
Enumeration Date:2021-08-31
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTPTP-PT-LIC-21996225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist