Provider Demographics
NPI:1588638092
Name:JORDAN, JEFFREY LAWRENCE (OD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:LAWRENCE
Last Name:JORDAN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:815 E COMMERCE ST
Mailing Address - Street 2:
Mailing Address - City:LEWISBURG
Mailing Address - State:TN
Mailing Address - Zip Code:37091-3515
Mailing Address - Country:US
Mailing Address - Phone:931-359-4373
Mailing Address - Fax:931-359-5772
Practice Address - Street 1:815 E COMMERCE ST
Practice Address - Street 2:
Practice Address - City:LEWISBURG
Practice Address - State:TN
Practice Address - Zip Code:37091-3515
Practice Address - Country:US
Practice Address - Phone:931-359-4373
Practice Address - Fax:931-359-5772
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-14
Last Update Date:2019-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2156152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3725865Medicaid
U82790Medicare UPIN
TN3725865Medicaid