Provider Demographics
NPI:1558331454
Name:JORDAN, MARCIA C, (MD)
Entity Type:Individual
Prefix:
First Name:MARCIA
Middle Name:C,
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 1:1412 SW 43RD ST
Mailing Address - Street 2:#200
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98057-4803
Mailing Address - Country:US
Mailing Address - Phone:425-271-4910
Mailing Address - Fax:425-264-1041
Practice Address - Street 1:1412 SW 43RD ST
Practice Address - Street 2:#200
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98057-4803
Practice Address - Country:US
Practice Address - Phone:425-271-4910
Practice Address - Fax:425-264-1041
Is Sole Proprietor?:No
Enumeration Date:2006-01-24
Last Update Date:2016-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00031325207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8156531Medicaid
WAF89374Medicare UPIN
WA8156531Medicaid