Provider Demographics
NPI:1285675215
Name:JORDAN, JOHN C (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:C
Last Name:JORDAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:JOHN
Other - Middle Name:C
Other - Last Name:JORDAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1035 E OLD HICKORY BLVD
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:TN
Mailing Address - Zip Code:37115
Mailing Address - Country:US
Mailing Address - Phone:615-868-6464
Mailing Address - Fax:615-868-7986
Practice Address - Street 1:1035 E OLD HICKORY BLVD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:TN
Practice Address - Zip Code:37115
Practice Address - Country:US
Practice Address - Phone:615-868-6464
Practice Address - Fax:615-868-7986
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-09
Last Update Date:2009-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD023806207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3069230Medicaid
TN3069230Medicaid
3069230Medicare ID - Type Unspecified