Provider Demographics
NPI:1275817496
Name:MORK, JAN HAKAN (PT)
Entity Type:Individual
Prefix:MR
First Name:JAN
Middle Name:HAKAN
Last Name:MORK
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 1:7677 W PARADISE LN
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85382-4961
Mailing Address - Country:US
Mailing Address - Phone:623-229-9632
Mailing Address - Fax:
Practice Address - Street 1:7677 W PARADISE LN
Practice Address - Street 2:APT 1083
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85382-4961
Practice Address - Country:US
Practice Address - Phone:623-229-9632
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-06
Last Update Date:2020-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ9678225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ157378Medicare PIN
AZZ63123Medicare PIN