Provider Demographics
NPI:1083060396
Name:JORDAN, KELLY (MD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:JORDAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3261 FRANKLIN AVE E APT 7
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98102-3858
Mailing Address - Country:US
Mailing Address - Phone:949-981-0626
Mailing Address - Fax:
Practice Address - Street 1:747 52ND ST
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609-1809
Practice Address - Country:US
Practice Address - Phone:510-428-3331
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-05
Last Update Date:2022-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60945855208000000X, 2080P0203X
LA3335422080P0203X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty