Provider Demographics
NPI:1689416216
Name:HOLM, JORDAN WILLIAM (PT)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:WILLIAM
Last Name:HOLM
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16055 OLD FOREST PT STE 101B
Mailing Address - Street 2:
Mailing Address - City:MONUMENT
Mailing Address - State:CO
Mailing Address - Zip Code:80132-8670
Mailing Address - Country:US
Mailing Address - Phone:719-247-8916
Mailing Address - Fax:
Practice Address - Street 1:16055 OLD FOREST PT STE 101B
Practice Address - Street 2:
Practice Address - City:MONUMENT
Practice Address - State:CO
Practice Address - Zip Code:80132-8670
Practice Address - Country:US
Practice Address - Phone:719-247-8916
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-12
Last Update Date:2024-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0019888225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist