Provider Demographics
NPI:1285861005
Name:GENUT, JORDAN ELLIOTT (MD)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:ELLIOTT
Last Name:GENUT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1115 SE 164TH AVE
Mailing Address - Street 2:DEPT. 358
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98683-9324
Mailing Address - Country:US
Mailing Address - Phone:877-202-3597
Mailing Address - Fax:
Practice Address - Street 1:2950 SQUALICUM PKWY
Practice Address - Street 2:SUITE B
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225-1857
Practice Address - Country:US
Practice Address - Phone:360-788-6063
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-19
Last Update Date:2014-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD604630582086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery