Provider Demographics
NPI:1417235185
Name:JONES, JORDAN KELLEY (OD)
Entity Type:Individual
Prefix:DR
First Name:JORDAN
Middle Name:KELLEY
Last Name:JONES
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 60352
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63160-0352
Mailing Address - Country:US
Mailing Address - Phone:314-362-3937
Mailing Address - Fax:866-505-8818
Practice Address - Street 1:450 N NEW BALLAS RD
Practice Address - Street 2:DEPT OPHTHALMOLOGY, STE 260
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-6859
Practice Address - Country:US
Practice Address - Phone:314-362-3937
Practice Address - Fax:866-505-8818
Is Sole Proprietor?:No
Enumeration Date:2011-07-29
Last Update Date:2024-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012018552152W00000X, 152WC0802X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO310007526Medicaid
MO067820037Medicare PIN
MO1417235185Medicaid