Healthcare Provider Details

I. General information

NPI: 1073241006
Provider Name (Legal Business Name): JORDAN NICHOL PUVOGEL DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2022
Last Update Date: 08/09/2022
Certification Date: 08/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 S FORREST AVE
LIBERTY MO
64068-1908
US

IV. Provider business mailing address

102 S FORREST AVE
LIBERTY MO
64068-1908
US

V. Phone/Fax

Practice location:
  • Phone: 816-429-5199
  • Fax: 816-429-7129
Mailing address:
  • Phone: 816-429-5199
  • Fax: 816-429-7129

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2022030907
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: