Basic Information
| Provider Information | |||||||||
| NPI: | 1821613969 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WOHLGEFAHRT | ||||||||
| FirstName: | JORDYN | ||||||||
| MiddleName: | KRIS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12464 PINEHURST CT | ||||||||
| Address2: | |||||||||
| City: | GULFPORT | ||||||||
| State: | MS | ||||||||
| PostalCode: | 395037678 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4142428342 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 9230 OLD LORRAINE RD | ||||||||
| Address2: | |||||||||
| City: | GULFPORT | ||||||||
| State: | MS | ||||||||
| PostalCode: | 395036059 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2287313500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2020 | ||||||||
| LastUpdateDate: | 06/15/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/15/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | RBT-20-121919 | MS | Y |
No ID Information.