Healthcare Provider Details

I. General information

NPI: 1609356070
Provider Name (Legal Business Name): JORDAN BORK DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2018
Last Update Date: 10/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

209 KIRKLAND AVE
KIRKLAND WA
98033-6503
US

IV. Provider business mailing address

209 KIRKLAND AVE
KIRKLAND WA
98033-6503
US

V. Phone/Fax

Practice location:
  • Phone: 425-629-3502
  • Fax: 425-629-3517
Mailing address:
  • Phone: 425-629-3502
  • Fax: 425-629-3517

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT60869454
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: