Provider Demographics
NPI:1235186438
Name:JORDAN, KENNETH A (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:A
Last Name:JORDAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:117 W PATERSON ST
Mailing Address - Street 2:ATTN: PAULA JACKSON
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49007
Mailing Address - Country:US
Mailing Address - Phone:269-349-2641
Mailing Address - Fax:269-201-2855
Practice Address - Street 1:295 MAPLE ST STE 202
Practice Address - Street 2:
Practice Address - City:TAWAS CITY
Practice Address - State:MI
Practice Address - Zip Code:48763-9352
Practice Address - Country:US
Practice Address - Phone:989-362-6108
Practice Address - Fax:989-362-0161
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2019-07-29
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI4301040286207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
B47399Medicare UPIN