Provider Demographics
NPI:1639513294
Name:JORDAN, BROOKE LEANN (DO)
Entity Type:Individual
Prefix:MRS
First Name:BROOKE
Middle Name:LEANN
Last Name:JORDAN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2901 BLEDSOE ST
Mailing Address - Street 2:APT 2493
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76107-1810
Mailing Address - Country:US
Mailing Address - Phone:817-291-4505
Mailing Address - Fax:
Practice Address - Street 1:1500 S MAIN ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-4917
Practice Address - Country:US
Practice Address - Phone:817-702-3431
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-24
Last Update Date:2016-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX573164390200000X
TXQ8521207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXQ8521OtherMEDICAL LICENSE