Provider Demographics
NPI:1467521328
Name:JORDAN, CRAIG LOGAN (DR OF CHIROPRACTIC)
Entity Type:Individual
Prefix:
First Name:CRAIG
Middle Name:LOGAN
Last Name:JORDAN
Suffix:
Gender:M
Credentials:DR OF CHIROPRACTIC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10817 W LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:WEST ALLIS
Mailing Address - State:WI
Mailing Address - Zip Code:53227-1127
Mailing Address - Country:US
Mailing Address - Phone:414-327-6767
Mailing Address - Fax:414-327-0988
Practice Address - Street 1:10817 W LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53227-1127
Practice Address - Country:US
Practice Address - Phone:414-327-6767
Practice Address - Fax:414-327-0988
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2011-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1341012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI000075481Medicare ID - Type Unspecified
T62354Medicare UPIN