1073269577 NPI number — JESSICA JORDAN OD LLC

Table of content: (NPI 1073269577)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073269577 NPI number — JESSICA JORDAN OD LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JESSICA JORDAN OD LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1073269577
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/23/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3900 YORKTOWNE BLVD APT 4904
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORT ORANGE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32129-6033
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
808-286-5529
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1771 DUNLAWTON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORT ORANGE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32127-4757
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
386-304-7360
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/23/2022

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
JORDAN
Authorized Official First Name:
JESSICA
Authorized Official Middle Name:
M
Authorized Official Title or Position:
OPTOMETIRST
Authorized Official Telephone Number:
808-286-5529

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)