Provider Demographics
NPI:1295403087
Name:JORDAN, JAY CHADWICK JR
Entity Type:Individual
Prefix:
First Name:JAY
Middle Name:CHADWICK
Last Name:JORDAN
Suffix:JR
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 1:7772 RIVERSIDE PKWY APT 202L
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136-7693
Mailing Address - Country:US
Mailing Address - Phone:580-318-4823
Mailing Address - Fax:
Practice Address - Street 1:7772 RIVERSIDE PKWY APT 202L
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-7693
Practice Address - Country:US
Practice Address - Phone:580-318-4823
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-06
Last Update Date:2021-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program