Provider Demographics
NPI:1518014794
Name:JORDAN, JODY LEA (MD)
Entity Type:Individual
Prefix:DR
First Name:JODY
Middle Name:LEA
Last Name:JORDAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 COAL AVE SE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106-5205
Mailing Address - Country:US
Mailing Address - Phone:505-938-5858
Mailing Address - Fax:505-938-5861
Practice Address - Street 1:1001 COAL AVE SE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106-5205
Practice Address - Country:US
Practice Address - Phone:505-938-5858
Practice Address - Fax:505-938-5861
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2007-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2006-0632174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM54654823Medicaid
NM54654823Medicaid
NM346711604Medicare PIN