Healthcare Provider Details

I. General information

NPI: 1477029221
Provider Name (Legal Business Name): JORDAN S BJORHUS DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2018
Last Update Date: 10/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1040 LINCOLN AVE
DETROIT LAKES MN
56501-3508
US

IV. Provider business mailing address

1702 UNIVERSITY DR S
FARGO ND
58103-4940
US

V. Phone/Fax

Practice location:
  • Phone: 218-847-5611
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number8983
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: