Provider Demographics
NPI:1073269577
Name:JESSICA JORDAN OD LLC
Entity Type:Organization
Organization Name:JESSICA JORDAN OD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETIRST
Authorized Official - Prefix:DR
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:M
Authorized Official - Last Name:JORDAN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:808-286-5529
Mailing Address - Street 1:3900 YORKTOWNE BLVD APT 4904
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32129-6033
Mailing Address - Country:US
Mailing Address - Phone:808-286-5529
Mailing Address - Fax:
Practice Address - Street 1:1771 DUNLAWTON AVE
Practice Address - Street 2:
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32127-4757
Practice Address - Country:US
Practice Address - Phone:386-304-7360
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-23
Last Update Date:2022-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty