Provider Demographics
NPI:1639843154
Name:PRUITT, JORDAN MATTHEW (DPT)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:MATTHEW
Last Name:PRUITT
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 1:25125 LOOKOUT DR
Mailing Address - Street 2:
Mailing Address - City:FORT RILEY
Mailing Address - State:KS
Mailing Address - Zip Code:66442-4619
Mailing Address - Country:US
Mailing Address - Phone:409-474-1409
Mailing Address - Fax:
Practice Address - Street 1:7672 ESTES RD
Practice Address - Street 2:
Practice Address - City:FORT RILEY
Practice Address - State:KS
Practice Address - Zip Code:66442-5778
Practice Address - Country:US
Practice Address - Phone:409-474-1409
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-07
Last Update Date:2021-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist