Provider Demographics
NPI:1477579316
Name:JORDAN, KRISTINA RUTH (OD)
Entity Type:Individual
Prefix:DR
First Name:KRISTINA
Middle Name:RUTH
Last Name:JORDAN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:KRISTINA
Other - Middle Name:RUTH
Other - Last Name:SWARTZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:5323 N MAIN ST.
Mailing Address - Street 2:
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46545
Mailing Address - Country:US
Mailing Address - Phone:574-273-2727
Mailing Address - Fax:574-273-2726
Practice Address - Street 1:5323 N MAIN ST.
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545
Practice Address - Country:US
Practice Address - Phone:574-273-2727
Practice Address - Fax:574-273-2726
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2019-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004328152W00000X
IN18003396A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
V06579Medicare UPIN