Provider Demographics
NPI:1558127928
Name:JORDAN, LARRY J III (LPN)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:J
Last Name:JORDAN
Suffix:III
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15675 AMBAUM BLVD SW
Mailing Address - Street 2:
Mailing Address - City:BURIEN
Mailing Address - State:WA
Mailing Address - Zip Code:98166-2523
Mailing Address - Country:US
Mailing Address - Phone:650-283-1592
Mailing Address - Fax:
Practice Address - Street 1:15675 AMBAUM BLVD SW
Practice Address - Street 2:
Practice Address - City:BURIEN
Practice Address - State:WA
Practice Address - Zip Code:98166-2523
Practice Address - Country:US
Practice Address - Phone:650-283-1592
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-23
Last Update Date:2024-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALP.61501117164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse