Provider Demographics
NPI:1114599370
Name:DRAKE, JORDYN AUDREY (DO)
Entity Type:Individual
Prefix:
First Name:JORDYN
Middle Name:AUDREY
Last Name:DRAKE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 S WEDGEWOOD LN
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62901-2148
Mailing Address - Country:US
Mailing Address - Phone:217-208-9232
Mailing Address - Fax:
Practice Address - Street 1:300 W OAK ST
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-1400
Practice Address - Country:US
Practice Address - Phone:618-536-6621
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-15
Last Update Date:2021-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125077767207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine