Provider Demographics
NPI:1669453320
Name:JORDAN, LISA (OD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:JORDAN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 GARDEN CTR
Mailing Address - Street 2:STE 100
Mailing Address - City:BROOMFIELD
Mailing Address - State:CO
Mailing Address - Zip Code:80020-7026
Mailing Address - Country:US
Mailing Address - Phone:303-469-1941
Mailing Address - Fax:303-469-6634
Practice Address - Street 1:4 GARDEN CTR
Practice Address - Street 2:STE 100
Practice Address - City:BROOMFIELD
Practice Address - State:CO
Practice Address - Zip Code:80020-7026
Practice Address - Country:US
Practice Address - Phone:303-469-1941
Practice Address - Fax:303-469-6634
Is Sole Proprietor?:No
Enumeration Date:2005-11-09
Last Update Date:2012-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2125152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
COD85444Medicare UPIN