Provider Demographics
NPI:1235491754
Name:BORMANN, JORDAN
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:BORMANN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4420 DIXIE HWY
Mailing Address - Street 2:SUITE 122
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40216-2988
Mailing Address - Country:US
Mailing Address - Phone:502-447-2750
Mailing Address - Fax:502-449-9062
Practice Address - Street 1:4420 DIXIE HWY
Practice Address - Street 2:SUITE 122
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40216-2988
Practice Address - Country:US
Practice Address - Phone:502-447-2750
Practice Address - Fax:502-449-9062
Is Sole Proprietor?:No
Enumeration Date:2012-06-11
Last Update Date:2013-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT27344225100000X
KYPT006022225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist