Provider Demographics
NPI:1548636939
Name:ESPESETH, JORDAN
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:ESPESETH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1805 CLYDE DR
Mailing Address - Street 2:
Mailing Address - City:THIEF RIVER FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:56701-4515
Mailing Address - Country:US
Mailing Address - Phone:218-689-4156
Mailing Address - Fax:
Practice Address - Street 1:1805 CLYDE DR
Practice Address - Street 2:
Practice Address - City:THIEF RIVER FALLS
Practice Address - State:MN
Practice Address - Zip Code:56701-4515
Practice Address - Country:US
Practice Address - Phone:218-689-4156
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-19
Last Update Date:2015-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2115205225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant