Provider Demographics
NPI:1467039925
Name:RICHARDSON, JORDAN (DPM)
Entity Type:Individual
Prefix:DR
First Name:JORDAN
Middle Name:
Last Name:RICHARDSON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17326 E BROOKS FARM RD
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85298-8805
Mailing Address - Country:US
Mailing Address - Phone:480-707-2393
Mailing Address - Fax:
Practice Address - Street 1:5169 S COTTONWOOD ST STE 303
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-6768
Practice Address - Country:US
Practice Address - Phone:800-548-6672
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-29
Last Update Date:2021-05-03
Deactivation Date:2021-03-29
Deactivation Code:
Reactivation Date:2021-05-03
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program