Provider Demographics
NPI:1376958009
Name:BACKSTROM, JORDAN
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:BACKSTROM
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 1:215 HIGHWAY 2 SW STUITE 103
Mailing Address - Street 2:
Mailing Address - City:RUGBY
Mailing Address - State:ND
Mailing Address - Zip Code:58368
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:215 HIGHWAY 2 SW STUITE 103
Practice Address - Street 2:
Practice Address - City:RUGBY
Practice Address - State:ND
Practice Address - Zip Code:58368
Practice Address - Country:US
Practice Address - Phone:701-351-0775
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-20
Last Update Date:2018-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1755225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1987654321Medicaid
ND1234567891Medicare NSC
ND0147258369Medicare PIN
ND9876543210Medicare UPIN
ND0123456789Medicare Oscar/Certification