Provider Demographics
NPI:1407213689
Name:SHALLOW, JORDAN M (DC)
Entity Type:Individual
Prefix:DR
First Name:JORDAN
Middle Name:M
Last Name:SHALLOW
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:241 POLARIS AVE
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN VIEW
Mailing Address - State:CA
Mailing Address - Zip Code:94043-4514
Mailing Address - Country:US
Mailing Address - Phone:408-966-7690
Mailing Address - Fax:
Practice Address - Street 1:241 POLARIS AVE
Practice Address - Street 2:
Practice Address - City:MOUNTAIN VIEW
Practice Address - State:CA
Practice Address - Zip Code:94043-4514
Practice Address - Country:US
Practice Address - Phone:408-966-7690
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-19
Last Update Date:2016-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA33455111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor