Provider Demographics
NPI:1578815551
Name:MALKOWSKI, JORDAN L K (PT)
Entity Type:Individual
Prefix:MRS
First Name:JORDAN
Middle Name:L K
Last Name:MALKOWSKI
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:603 S GILLETTE AVE
Mailing Address - Street 2:
Mailing Address - City:GILLETTE
Mailing Address - State:WY
Mailing Address - Zip Code:82716-4205
Mailing Address - Country:US
Mailing Address - Phone:307-682-2500
Mailing Address - Fax:307-939-7080
Practice Address - Street 1:603 S GILLETTE AVE
Practice Address - Street 2:
Practice Address - City:GILLETTE
Practice Address - State:WY
Practice Address - Zip Code:82716-4205
Practice Address - Country:US
Practice Address - Phone:307-682-2500
Practice Address - Fax:307-939-7080
Is Sole Proprietor?:No
Enumeration Date:2012-10-15
Last Update Date:2020-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY1436225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist