Provider Demographics
NPI:1174901490
Name:PROBASCO, JORDAN GUY (DC)
Entity type:Individual
Prefix:DR
First Name:JORDAN
Middle Name:GUY
Last Name:PROBASCO
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1039 SE 78TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97215-3006
Mailing Address - Country:US
Mailing Address - Phone:509-435-7124
Mailing Address - Fax:
Practice Address - Street 1:12661 SE POWELL BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97236-3400
Practice Address - Country:US
Practice Address - Phone:503-801-8888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-07
Last Update Date:2015-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR5631111N00000X, 111NP0017X, 111NR0400X, 111NX0100X, 111NX0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No111NP0017XChiropractic ProvidersChiropractorPediatric Chiropractor
No111NR0400XChiropractic ProvidersChiropractorRehabilitation
No111NX0100XChiropractic ProvidersChiropractorOccupational Health
No111NX0800XChiropractic ProvidersChiropractorOrthopedic