Provider Demographics
NPI:1326401290
Name:MAIVELETT, JORDAN (MD)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:MAIVELETT
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 1:25 E DELAWARE PL
Mailing Address - Street 2:APT 306
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-1828
Mailing Address - Country:US
Mailing Address - Phone:803-292-4936
Mailing Address - Fax:
Practice Address - Street 1:211 E ONTARIO ST
Practice Address - Street 2:SUITE 200
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-3468
Practice Address - Country:US
Practice Address - Phone:312-926-9512
Practice Address - Fax:312-926-6274
Is Sole Proprietor?:No
Enumeration Date:2016-03-30
Last Update Date:2017-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL125-068371207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program