=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508365115
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JORDAN WILLIAM PONTIUS DC, ATC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/09/2018
-----------------------------------------------------
Last Update Date | 10/31/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 630 TERRA WEST DR
-----------------------------------------------------
City | FREEPORT
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61032
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-235-7858
-----------------------------------------------------
Fax | 815-235-7913
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 627 N GREENFIELD DR
-----------------------------------------------------
City | FREEPORT
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61032-2914
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-990-5394
-----------------------------------------------------
Fax | 815-235-7913
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 038.013188
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------