Provider Demographics
NPI:1407998628
Name:JORDAN, KEVIN S (DC)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:S
Last Name:JORDAN
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 1:8889 MENTOR AVENUE
Mailing Address - Street 2:
Mailing Address - City:MENTOR
Mailing Address - State:OH
Mailing Address - Zip Code:44060
Mailing Address - Country:US
Mailing Address - Phone:440-205-1889
Mailing Address - Fax:440-205-1890
Practice Address - Street 1:8889 MENTOR AVENUE
Practice Address - Street 2:
Practice Address - City:MENTOR
Practice Address - State:OH
Practice Address - Zip Code:44060
Practice Address - Country:US
Practice Address - Phone:440-205-1889
Practice Address - Fax:440-205-1890
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-13
Last Update Date:2015-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1989111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH34-1843246-00OtherBWC PROVIDER NUMBER
OH34-1843246-00OtherBWC PROVIDER NUMBER
OH0754002Medicare ID - Type Unspecified
OH34-1843246OtherTAX ID NUMBER