Provider Demographics
NPI:1710189873
Name:JORDAN, JANICE LYNN
Entity Type:Individual
Prefix:
First Name:JANICE
Middle Name:LYNN
Last Name:JORDAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3723 S BOLIVAR RD
Mailing Address - Street 2:
Mailing Address - City:SPOKANE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:99037-8382
Mailing Address - Country:US
Mailing Address - Phone:208-568-0110
Mailing Address - Fax:
Practice Address - Street 1:12418 E SALTESE AVE
Practice Address - Street 2:
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99216-0357
Practice Address - Country:US
Practice Address - Phone:509-822-7719
Practice Address - Fax:509-822-7986
Is Sole Proprietor?:No
Enumeration Date:2007-06-01
Last Update Date:2015-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10005211363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MTS71883Medicare UPIN