Provider Demographics
NPI:1114159860
Name:DORN, JUSTIN (PT, DPT)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:DORN
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:641 W WILLOUGHBY AVE STE 206
Mailing Address - Street 2:
Mailing Address - City:JUNEAU
Mailing Address - State:AK
Mailing Address - Zip Code:99801-1748
Mailing Address - Country:US
Mailing Address - Phone:907-586-5951
Mailing Address - Fax:
Practice Address - Street 1:641 W WILLOUGHBY AVE STE 206
Practice Address - Street 2:
Practice Address - City:JUNEAU
Practice Address - State:AK
Practice Address - Zip Code:99801-1748
Practice Address - Country:US
Practice Address - Phone:907-586-5951
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-13
Last Update Date:2009-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK2079225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist