Provider Demographics
NPI:1871199471
Name:VANDYCK, JORDAN (DPT)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:VANDYCK
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5764 S 108TH ST
Mailing Address - Street 2:
Mailing Address - City:HALES CORNERS
Mailing Address - State:WI
Mailing Address - Zip Code:53130-1947
Mailing Address - Country:US
Mailing Address - Phone:414-400-7110
Mailing Address - Fax:414-400-7112
Practice Address - Street 1:5764 S 108TH ST
Practice Address - Street 2:
Practice Address - City:HALES CORNERS
Practice Address - State:WI
Practice Address - Zip Code:53130-1947
Practice Address - Country:US
Practice Address - Phone:414-400-7110
Practice Address - Fax:414-400-7112
Is Sole Proprietor?:No
Enumeration Date:2020-12-09
Last Update Date:2024-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15231-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist