Provider Demographics
NPI:1992417489
Name:GROENNERT, JORDAN (DPT)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:GROENNERT
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12723 CRESTVIEW LN
Mailing Address - Street 2:
Mailing Address - City:TRENTON
Mailing Address - State:IL
Mailing Address - Zip Code:62293-1430
Mailing Address - Country:US
Mailing Address - Phone:618-830-9333
Mailing Address - Fax:
Practice Address - Street 1:12866 TROXLER AVE
Practice Address - Street 2:
Practice Address - City:HIGHLAND
Practice Address - State:IL
Practice Address - Zip Code:62249-2806
Practice Address - Country:US
Practice Address - Phone:618-651-2600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-16
Last Update Date:2022-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist