Provider Demographics
NPI:1447385950
Name:JORDAN, JERRY J (EDD, CTRS)
Entity Type:Individual
Prefix:PROF
First Name:JERRY
Middle Name:J
Last Name:JORDAN
Suffix:
Gender:M
Credentials:EDD, CTRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 DONNA AVE
Mailing Address - Street 2:
Mailing Address - City:GUTHRIE
Mailing Address - State:OK
Mailing Address - Zip Code:73044-9494
Mailing Address - Country:US
Mailing Address - Phone:405-744-9424
Mailing Address - Fax:405-744-6507
Practice Address - Street 1:325 DONNA AVE
Practice Address - Street 2:
Practice Address - City:GUTHRIE
Practice Address - State:OK
Practice Address - Zip Code:73044-9494
Practice Address - Country:US
Practice Address - Phone:405-744-9424
Practice Address - Fax:405-744-6507
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist