Provider Demographics
NPI:1659489300
Name:JORDAN, RUSSELL O (DC)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:O
Last Name:JORDAN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3039 W 1500N RD
Mailing Address - Street 2:
Mailing Address - City:KANKAKEE
Mailing Address - State:IL
Mailing Address - Zip Code:60901-8350
Mailing Address - Country:US
Mailing Address - Phone:815-939-0243
Mailing Address - Fax:
Practice Address - Street 1:3039 W 1500N RD
Practice Address - Street 2:
Practice Address - City:KANKAKEE
Practice Address - State:IL
Practice Address - Zip Code:60901-8350
Practice Address - Country:US
Practice Address - Phone:815-939-0243
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL270240Medicare ID - Type UnspecifiedGRP
ILT335831Medicare UPIN