Provider Demographics
NPI:1497364475
Name:ANDERSON, JORDYN B
Entity Type:Individual
Prefix:
First Name:JORDYN
Middle Name:B
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4724 BIRCH WAY
Mailing Address - Street 2:
Mailing Address - City:SIOUX CITY
Mailing Address - State:IA
Mailing Address - Zip Code:51106-9528
Mailing Address - Country:US
Mailing Address - Phone:712-899-1691
Mailing Address - Fax:
Practice Address - Street 1:4500 SERGEANT RD
Practice Address - Street 2:
Practice Address - City:SIOUX CITY
Practice Address - State:IA
Practice Address - Zip Code:51106-4705
Practice Address - Country:US
Practice Address - Phone:712-274-2949
Practice Address - Fax:712-274-8072
Is Sole Proprietor?:No
Enumeration Date:2020-07-27
Last Update Date:2020-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA23874183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist