Provider Demographics
NPI:1750912291
Name:SHILTS, JORDAN
Entity type:Individual
Prefix:DR
First Name:JORDAN
Middle Name:
Last Name:SHILTS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4820 W 77TH ST STE 150
Mailing Address - Street 2:
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-4822
Mailing Address - Country:US
Mailing Address - Phone:920-323-2243
Mailing Address - Fax:
Practice Address - Street 1:4820 W 77TH ST STE 150
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-4822
Practice Address - Country:US
Practice Address - Phone:920-323-2243
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-03
Last Update Date:2020-09-18
Deactivation Date:2020-03-04
Deactivation Code:
Reactivation Date:2020-09-18
Provider Licenses
StateLicense IDTaxonomies
MN6704111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor