Provider Demographics
NPI:1396188025
Name:MARSHALL, JORDAN KENNETH (MD)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:KENNETH
Last Name:MARSHALL
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 1:7383 HAZEL AVE
Mailing Address - Street 2:
Mailing Address - City:MAPLEWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63143-3223
Mailing Address - Country:US
Mailing Address - Phone:907-482-3613
Mailing Address - Fax:
Practice Address - Street 1:2001 STATE ST
Practice Address - Street 2:
Practice Address - City:EAST SAINT LOUIS
Practice Address - State:IL
Practice Address - Zip Code:62205-1803
Practice Address - Country:US
Practice Address - Phone:618-271-0204
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-11
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01012571592083A0100X, 208D00000X
IL036160684207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No2083A0100XAllopathic & Osteopathic PhysiciansPreventive MedicineAerospace Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice