Healthcare Provider Details

I. General information

NPI: 1164401667
Provider Name (Legal Business Name): BOYD KENNETH JORDAN P.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/12/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 N TOWNSHIP ST SUITE F
SEDRO WOOLLEY WA
98284-1232
US

IV. Provider business mailing address

108 N TOWNSHIP ST SUITE F
SEDRO WOOLLEY WA
98284-1232
US

V. Phone/Fax

Practice location:
  • Phone: 360-854-9924
  • Fax: 360-854-9743
Mailing address:
  • Phone: 360-854-9924
  • Fax: 360-854-9743

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT00006044
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: