Healthcare Provider Details

I. General information

NPI: 1659058915
Provider Name (Legal Business Name): JORDAN DONZE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2023
Last Update Date: 06/29/2023
Certification Date: 06/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12626 LAMPLIGHTER SQUARE SHOPPING CENTER
SAINT LOUIS MO
63128
US

IV. Provider business mailing address

11727 PARK HAVEN CT
SAINT LOUIS MO
63126-3071
US

V. Phone/Fax

Practice location:
  • Phone: 314-842-4222
  • Fax:
Mailing address:
  • Phone: 314-702-3210
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2023023363
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: