Provider Demographics
NPI:1447734579
Name:SMITH, JORDAN (BC-HIS)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:BC-HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:843 W SUMMIT AVE
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49441-4047
Mailing Address - Country:US
Mailing Address - Phone:231-755-3920
Mailing Address - Fax:
Practice Address - Street 1:843 W SUMMIT AVE
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49441-4047
Practice Address - Country:US
Practice Address - Phone:231-755-3920
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-25
Last Update Date:2018-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI3501007968237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument SpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3501007968OtherHEARING AID SALESPERSON