Provider Demographics
NPI:1649934324
Name:MANTELS, JORDAN MARIE
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:MARIE
Last Name:MANTELS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:820 HILLCREST DR
Mailing Address - Street 2:
Mailing Address - City:OWENSVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:65066-2823
Mailing Address - Country:US
Mailing Address - Phone:573-301-2278
Mailing Address - Fax:
Practice Address - Street 1:509 W 18TH ST
Practice Address - Street 2:
Practice Address - City:HERMANN
Practice Address - State:MO
Practice Address - Zip Code:65041-1547
Practice Address - Country:US
Practice Address - Phone:573-486-2154
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-28
Last Update Date:2021-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014037305225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant