Provider Demographics
NPI:1588043871
Name:ROBERTS, JORDAN RUSSELL (MD)
Entity Type:Individual
Prefix:DR
First Name:JORDAN
Middle Name:RUSSELL
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:JORDAN
Other - Middle Name:
Other - Last Name:ESSARY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:999 E MURRAY HOLLADAY RD STE 207
Mailing Address - Street 2:
Mailing Address - City:HOLLADAY
Mailing Address - State:UT
Mailing Address - Zip Code:84117-5093
Mailing Address - Country:US
Mailing Address - Phone:801-268-2584
Mailing Address - Fax:801-262-1168
Practice Address - Street 1:999 E MURRAY HOLLADAY RD STE 207
Practice Address - Street 2:
Practice Address - City:HOLLADAY
Practice Address - State:UT
Practice Address - Zip Code:84117-5093
Practice Address - Country:US
Practice Address - Phone:801-268-2584
Practice Address - Fax:801-262-1168
Is Sole Proprietor?:No
Enumeration Date:2015-05-20
Last Update Date:2018-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9897039-1205207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine