Provider Demographics
NPI:1710081708
Name:JORDAN, KENNETH N (DO)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:N
Last Name:JORDAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 WEST MADISON
Mailing Address - Street 2:
Mailing Address - City:PONTIAC
Mailing Address - State:IL
Mailing Address - Zip Code:61764
Mailing Address - Country:US
Mailing Address - Phone:815-844-6106
Mailing Address - Fax:815-842-2526
Practice Address - Street 1:520 WEST MADISON STREET
Practice Address - Street 2:MADISON STREET CLINIC PC
Practice Address - City:PONTIAC
Practice Address - State:IL
Practice Address - Zip Code:61764
Practice Address - Country:US
Practice Address - Phone:815-844-6106
Practice Address - Fax:815-842-2526
Is Sole Proprietor?:No
Enumeration Date:2006-09-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL003036052185207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036052185Medicaid
IL036052185Medicaid
IL219130Medicare ID - Type Unspecified