Provider Demographics
NPI:1619105038
Name:ALTEKRUSE, JORDAN C (DPT)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:C
Last Name:ALTEKRUSE
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12201 TULLAMORE RD
Mailing Address - Street 2:
Mailing Address - City:TIMONIUM
Mailing Address - State:MD
Mailing Address - Zip Code:21093-7816
Mailing Address - Country:US
Mailing Address - Phone:410-308-7850
Mailing Address - Fax:410-308-7851
Practice Address - Street 1:12201 TULLAMORE RD
Practice Address - Street 2:
Practice Address - City:TIMONIUM
Practice Address - State:MD
Practice Address - Zip Code:21093-7816
Practice Address - Country:US
Practice Address - Phone:410-308-7850
Practice Address - Fax:410-308-7851
Is Sole Proprietor?:No
Enumeration Date:2009-06-24
Last Update Date:2014-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD22953225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist