1972167161 NPI number — DR. JORDAN MICHAEL ELLIS PHD

Table of content: DR. JORDAN MICHAEL ELLIS PHD (NPI 1972167161)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972167161 NPI number — DR. JORDAN MICHAEL ELLIS PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ELLIS
Provider First Name:
JORDAN
Provider Middle Name:
MICHAEL
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PHD
Provider Gender Code:
M

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:
1972167161
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/16/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1100 WILFORD HALL LOOP
Provider Second Line Business Mailing Address:
BLDG. 4554, 59 MDW/GME, JBSA LACKLAND
Provider Business Mailing Address City Name:
JBSA LACKLAND
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78236
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1060 W PERIMETER RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JB ANDREWS
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
20762-6602
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
240-857-7186
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/24/2019

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103TH0004X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TC0700X , with the licence number: 0810007310 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2025 www.npivalidator.com