MEDICARE: JORDAN LEE MITZEL DPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist

General Provider Information

NPI Number	:	1679031165
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JORDAN LEE MITZEL DPT

Provider Business Mailing Address
First Line	:	PO BOX 765
Second Line	:
City	:	CROOKS
State	:	SD
Zip	:	57020-0765
Country	:	US
Telephone Number	:	605-360-0229
Fax Number	:

Provider Business Practice Location Address
First Line	:	2419 2ND AVE N
Second Line	:
City	:	FORT DODGE
State	:	IA
Zip	:	50501-3602
Country	:	US
Telephone Number	:	515-576-2235
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/04/2019
Last Update Date	:	03/04/2019

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Directions to “ JORDAN LEE MITZEL DPT” Practice Location

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