Healthcare Provider Details

I. General information

NPI: 1073115382
Provider Name (Legal Business Name): JORDAN STODDARD DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/11/2020
Last Update Date: 12/03/2020
Certification Date: 12/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

804 PANCHERI DR
IDAHO FALLS ID
83402-3344
US

IV. Provider business mailing address

3716 E 343 N
RIGBY ID
83442-5326
US

V. Phone/Fax

Practice location:
  • Phone: 208-403-7422
  • Fax:
Mailing address:
  • Phone: 208-403-7422
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2251C2600X
TaxonomyCardiopulmonary Physical Therapist
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code2251G0304X
TaxonomyGeriatric Physical Therapist
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number
License Number StateNULL
# 5
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License NumberPT-3572
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: