Provider Demographics
NPI:1417495490
Name:JORDAN, CHRISTOPHER HENRY
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:HENRY
Last Name:JORDAN
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 1:1702 WESTCLIFF DR
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37803-6300
Mailing Address - Country:US
Mailing Address - Phone:865-384-9943
Mailing Address - Fax:
Practice Address - Street 1:225 BENNETT AVE
Practice Address - Street 2:
Practice Address - City:HURLBURT FLD
Practice Address - State:FL
Practice Address - Zip Code:32544-5707
Practice Address - Country:US
Practice Address - Phone:850-884-1100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-09
Last Update Date:2022-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NE30984208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program