Provider Demographics
NPI:1477959328
Name:BRADY, JORDAN WILLIAM
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:WILLIAM
Last Name:BRADY
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 1:1940 S BONITO WAY STE 190
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-5618
Mailing Address - Country:US
Mailing Address - Phone:208-287-9420
Mailing Address - Fax:
Practice Address - Street 1:2121 N 1700 W STE A
Practice Address - Street 2:
Practice Address - City:LAYTON
Practice Address - State:UT
Practice Address - Zip Code:84041-8804
Practice Address - Country:US
Practice Address - Phone:801-773-1350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-04
Last Update Date:2023-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
ID6623225100000X
UT10405007-2401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No171M00000XOther Service ProvidersCase Manager/Care Coordinator