Provider Demographics
NPI:1477190908
Name:IVY, JORDAN MARKEIS JAMES
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:MARKEIS JAMES
Last Name:IVY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5135 CAMINO AL NORTE STE 150
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89031-2388
Mailing Address - Country:US
Mailing Address - Phone:702-853-6714
Mailing Address - Fax:
Practice Address - Street 1:5135 CAMINO AL NORTE STE 150
Practice Address - Street 2:
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89031-2388
Practice Address - Country:US
Practice Address - Phone:702-853-6714
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-03
Last Update Date:2019-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No376J00000XNursing Service Related ProvidersHomemaker