Provider Demographics
NPI:1326459892
Name:JORDAN, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:JORDAN
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 1:300 HARTFORD DR
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:OH
Mailing Address - Zip Code:43130-1571
Mailing Address - Country:US
Mailing Address - Phone:740-407-8287
Mailing Address - Fax:
Practice Address - Street 1:300 HARTFORD DR
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:OH
Practice Address - Zip Code:43130-1571
Practice Address - Country:US
Practice Address - Phone:740-407-8287
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-18
Last Update Date:2014-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH04012003Medicare Oscar/Certification