Provider Demographics
NPI:1710356365
Name:VISSER, JORDAN NICHOLAS (PT)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:NICHOLAS
Last Name:VISSER
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2025 NE BAKER ST.
Mailing Address - Street 2:SUITE A
Mailing Address - City:MCMINNVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97128
Mailing Address - Country:US
Mailing Address - Phone:503-435-1900
Mailing Address - Fax:503-435-1930
Practice Address - Street 1:2025 NE BAKER ST.
Practice Address - Street 2:SUITE A
Practice Address - City:MCMINNVILLE
Practice Address - State:OR
Practice Address - Zip Code:97128
Practice Address - Country:US
Practice Address - Phone:503-435-1900
Practice Address - Fax:503-435-1930
Is Sole Proprietor?:No
Enumeration Date:2015-09-24
Last Update Date:2015-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR61014225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist