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General NPI Number Information
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NPI Number | 1548901176
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Entity Type | Individual
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Provider Name | JORDAN BROOK MOCKTA ACSM-EP
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Gender | Male
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Dates
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Enumeration Date | 04/06/2022
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Last Update Date | 04/11/2022
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Provider Practice Location Address
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Address Line | 1500 E CEDAR AVE STE 52
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City | FLAGSTAFF
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State | AZ
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Zip | 86004-1643
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Country | US
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Telephone | 928-773-1245
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Fax | 928-773-9429
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Provider Business Mailing Address
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Address Line | 5404 E. CORTLAND BLVD 190
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City | FLAGSTAFF
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State | AZ
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Zip | 86004
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Country | US
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Telephone | 928-255-7867
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 224Y00000X
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Taxonomy Name | Clinical Exercise Physiologist
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License Number | 1059346
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License Number State | AZ
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