Provider Demographics
NPI:1164401667
Name:JORDAN, BOYD KENNETH (PT)
Entity Type:Individual
Prefix:MR
First Name:BOYD
Middle Name:KENNETH
Last Name:JORDAN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 N TOWNSHIP ST
Mailing Address - Street 2:SUITE F
Mailing Address - City:SEDRO WOOLLEY
Mailing Address - State:WA
Mailing Address - Zip Code:98284-1232
Mailing Address - Country:US
Mailing Address - Phone:360-854-9924
Mailing Address - Fax:360-854-9743
Practice Address - Street 1:108 N TOWNSHIP ST
Practice Address - Street 2:SUITE F
Practice Address - City:SEDRO WOOLLEY
Practice Address - State:WA
Practice Address - Zip Code:98284-1232
Practice Address - Country:US
Practice Address - Phone:360-854-9924
Practice Address - Fax:360-854-9743
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-12
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00006044225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7112295Medicaid
WAAB28603Medicare ID - Type Unspecified