Provider Demographics
NPI:1417674151
Name:MARTIN, JORDAN
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21531 SW ATHEY RD
Mailing Address - Street 2:
Mailing Address - City:WEST LINN
Mailing Address - State:OR
Mailing Address - Zip Code:97068-9710
Mailing Address - Country:US
Mailing Address - Phone:503-679-7294
Mailing Address - Fax:
Practice Address - Street 1:21531 SW ATHEY RD
Practice Address - Street 2:
Practice Address - City:WEST LINN
Practice Address - State:OR
Practice Address - Zip Code:97068-9710
Practice Address - Country:US
Practice Address - Phone:503-679-7294
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-24
Last Update Date:2022-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201805777RN163WX0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WX0003XNursing Service ProvidersRegistered NurseObstetric, Inpatient