Provider Demographics
NPI:1336890755
Name:WOLAK, JORDAN (ATC, PT, DPT)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:WOLAK
Suffix:
Gender:F
Credentials:ATC, PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 332
Mailing Address - Street 2:
Mailing Address - City:PENGILLY
Mailing Address - State:MN
Mailing Address - Zip Code:55775-0332
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3131 S VAUGHN WAY STE 125
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80014-3501
Practice Address - Country:US
Practice Address - Phone:303-755-1116
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-17
Last Update Date:2023-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPT-32107225100000X
MN12506225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist