Provider Demographics
NPI:1992693808
Name:PRUNTY, JORDAN CRAIG (PT, DPT)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:CRAIG
Last Name:PRUNTY
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11489 SW GABRIEL ST
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97224-4062
Mailing Address - Country:US
Mailing Address - Phone:971-777-0001
Mailing Address - Fax:
Practice Address - Street 1:11105 SW GREENBURG RD
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223-5446
Practice Address - Country:US
Practice Address - Phone:971-294-2669
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-27
Last Update Date:2025-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR65742225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist