Provider Demographics
NPI:1508365115
Name:PONTIUS, JORDAN WILLIAM (DC, ATC)
Entity Type:Individual
Prefix:DR
First Name:JORDAN
Middle Name:WILLIAM
Last Name:PONTIUS
Suffix:
Gender:M
Credentials:DC, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:627 N GREENFIELD DR
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:IL
Mailing Address - Zip Code:61032-2914
Mailing Address - Country:US
Mailing Address - Phone:815-990-5394
Mailing Address - Fax:815-235-7913
Practice Address - Street 1:630 TERRA WEST DR
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:IL
Practice Address - Zip Code:61032
Practice Address - Country:US
Practice Address - Phone:815-235-7858
Practice Address - Fax:815-235-7913
Is Sole Proprietor?:No
Enumeration Date:2018-02-09
Last Update Date:2019-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038.013188111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL765879632OtherBCBS
IL6217986OtherAENTA