Provider Demographics
NPI:1851196174
Name:KONDIKOFF, JORDAN
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:KONDIKOFF
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:234 CLAIRMONT DR
Mailing Address - Street 2:
Mailing Address - City:PONDER
Mailing Address - State:TX
Mailing Address - Zip Code:76259-1003
Mailing Address - Country:US
Mailing Address - Phone:214-704-4894
Mailing Address - Fax:
Practice Address - Street 1:2900 W WASHINGTON ST STE 74A
Practice Address - Street 2:
Practice Address - City:STEPHENVILLE
Practice Address - State:TX
Practice Address - Zip Code:76401-3736
Practice Address - Country:US
Practice Address - Phone:431-510-0254
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-19
Last Update Date:2025-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1403487225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist