Provider Demographics
NPI:1689941999
Name:JORDAN, IVY L (DPT)
Entity Type:Individual
Prefix:
First Name:IVY
Middle Name:L
Last Name:JORDAN
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:IVY
Other - Middle Name:L
Other - Last Name:ROE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3155 BLUESTEM DR
Mailing Address - Street 2:
Mailing Address - City:WEST FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58078-8002
Mailing Address - Country:US
Mailing Address - Phone:701-353-5476
Mailing Address - Fax:
Practice Address - Street 1:736 BROADWAY N
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58102
Practice Address - Country:US
Practice Address - Phone:701-234-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-30
Last Update Date:2018-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCPT871270225100000X
MN11224225100000X
VA2305206961225100000X
ND2065225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist