Provider Demographics
NPI:1407146582
Name:DIVINE, JORDAN R
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:R
Last Name:DIVINE
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 1:407 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LOOGOOTEE
Mailing Address - State:IN
Mailing Address - Zip Code:47553-1241
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:404 N JOHN F KENNEDY AVE
Practice Address - Street 2:
Practice Address - City:LOOGOOTEE
Practice Address - State:IN
Practice Address - Zip Code:47553-1219
Practice Address - Country:US
Practice Address - Phone:812-295-5600
Practice Address - Fax:812-295-5700
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-11
Last Update Date:2011-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08002579A111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1407146582Medicare PIN