Provider Demographics
NPI:1548901176
Name:MOCKTA, JORDAN BROOK (ACSM-EP)
Entity type:Individual
Prefix:MR
First Name:JORDAN
Middle Name:BROOK
Last Name:MOCKTA
Suffix:
Gender:M
Credentials:ACSM-EP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5404 E. CORTLAND BLVD 190
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86004
Mailing Address - Country:US
Mailing Address - Phone:928-255-7867
Mailing Address - Fax:
Practice Address - Street 1:1500 E CEDAR AVE STE 52
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86004-1643
Practice Address - Country:US
Practice Address - Phone:928-773-1245
Practice Address - Fax:928-773-9429
Is Sole Proprietor?:No
Enumeration Date:2022-04-06
Last Update Date:2022-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1059346224Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Y00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersClinical Exercise Physiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZD04316506Medicaid