Provider Demographics
NPI:1679630685
Name:JORDAN, KATHLEEN T (MD)
Entity Type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:T
Last Name:JORDAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4128 24TH ST
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94114-3615
Mailing Address - Country:US
Mailing Address - Phone:415-753-4546
Mailing Address - Fax:650-641-3290
Practice Address - Street 1:4128 24TH ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94114-3615
Practice Address - Country:US
Practice Address - Phone:415-753-4546
Practice Address - Fax:650-641-3290
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2015-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG84721207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G847210Medicaid
CA00G847210Medicare PIN
CA00G847210Medicaid