Provider Demographics
NPI:1417048554
Name:JORDAN, JACOB (MD)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:JORDAN
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 1:2234 COLONIAL BLVD.
Mailing Address - Street 2:ATTN: MANAGED CARE DEPT.
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907
Mailing Address - Country:US
Mailing Address - Phone:239-931-7342
Mailing Address - Fax:239-931-7385
Practice Address - Street 1:2335 TAMIAMI TRAIL N.
Practice Address - Street 2:SUITE 501
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34103-4456
Practice Address - Country:US
Practice Address - Phone:239-263-0011
Practice Address - Fax:239-430-7823
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2017-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0047319208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP00877422OtherRR MEDICARE
FLP305081OtherFREEDOM
FL08461OtherBCBS
FL201912OtherWELLCARE
FL5954082OtherAETNA
FL057907600Medicaid
FL292168OtherAVMED
FLQMP000005106623OtherMOLINA
FLP953733OtherOPTIMUM
FLP953733OtherOPTIMUM
FLP305081OtherFREEDOM
FL08461VMedicare PIN