Provider Demographics
NPI:1225680853
Name:EVANS, JORDAN (OD)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:EVANS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2801 PARK MARINA DR
Mailing Address - Street 2:
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96001-2822
Mailing Address - Country:US
Mailing Address - Phone:530-244-2273
Mailing Address - Fax:530-244-2708
Practice Address - Street 1:2801 PARK MARINA DR
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96001-2822
Practice Address - Country:US
Practice Address - Phone:530-244-2273
Practice Address - Fax:530-244-2708
Is Sole Proprietor?:No
Enumeration Date:2019-07-13
Last Update Date:2021-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2358152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZOPT-002358OtherARIZONA OPTOMETRY LICENSE