Provider Demographics
NPI:1275284598
Name:JACK, JORDAN RILEY
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:RILEY
Last Name:JACK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2608 EAGLE POINT CT
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50320-2838
Mailing Address - Country:US
Mailing Address - Phone:515-783-8297
Mailing Address - Fax:
Practice Address - Street 1:223 FORKER BUILDING 534 WALLACE RD
Practice Address - Street 2:
Practice Address - City:AMES
Practice Address - State:IA
Practice Address - Zip Code:50011-0001
Practice Address - Country:US
Practice Address - Phone:515-783-8297
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-18
Last Update Date:2022-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program