Provider Demographics
NPI:1720180813
Name:JORDAN, JASON BRENT (DMD)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:BRENT
Last Name:JORDAN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 129
Mailing Address - Street 2:
Mailing Address - City:ASHVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35953
Mailing Address - Country:US
Mailing Address - Phone:205-594-5044
Mailing Address - Fax:205-594-5388
Practice Address - Street 1:279 5TH AVE
Practice Address - Street 2:
Practice Address - City:ASHVILLE
Practice Address - State:AL
Practice Address - Zip Code:35953
Practice Address - Country:US
Practice Address - Phone:205-594-5044
Practice Address - Fax:205-594-5044
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL5192122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
38963Medicare UPIN