Provider Demographics
NPI:1841967759
Name:KRUCEK, JORDAN PATRICK
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:PATRICK
Last Name:KRUCEK
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 1:6765 STRATHMORE DR
Mailing Address - Street 2:
Mailing Address - City:VALLEY VIEW
Mailing Address - State:OH
Mailing Address - Zip Code:44125
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:110 S MADISON ST
Practice Address - Street 2:
Practice Address - City:ADRIAN
Practice Address - State:MI
Practice Address - Zip Code:49221-2518
Practice Address - Country:US
Practice Address - Phone:216-299-8583
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-27
Last Update Date:2021-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer