Provider Demographics
NPI:1477934800
Name:FOHEY, JORDAN
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:FOHEY
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 1:2105 KARA CT
Mailing Address - Street 2:STE 1-A
Mailing Address - City:LIBERTY
Mailing Address - State:MO
Mailing Address - Zip Code:64068-1395
Mailing Address - Country:US
Mailing Address - Phone:816-407-1249
Mailing Address - Fax:816-407-1259
Practice Address - Street 1:2105 KARA CT
Practice Address - Street 2:SUITE A1
Practice Address - City:LIBERTY
Practice Address - State:MO
Practice Address - Zip Code:64068-1392
Practice Address - Country:US
Practice Address - Phone:816-407-1249
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-11
Last Update Date:2016-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015017610225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist