Healthcare Provider Details

I. General information

NPI: 1225393903
Provider Name (Legal Business Name): JORDAN NICOLE PAUTLER PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/10/2012
Last Update Date: 07/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2011 CORONA RD SUITE 301
COLUMBIA MISSOURI
65203
UM

IV. Provider business mailing address

2011 CORONA RD SUITE 301
COLUMBIA MO
65203-2548
US

V. Phone/Fax

Practice location:
  • Phone: 314-543-3860
  • Fax: 314-272-0343
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2012022170
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: