Provider Demographics
NPI:1720188493
Name:JORDAN, LAUREL (DO)
Entity Type:Individual
Prefix:
First Name:LAUREL
Middle Name:
Last Name:JORDAN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:530 N MONTE VISTA ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:ADA
Mailing Address - State:OK
Mailing Address - Zip Code:74820-4675
Mailing Address - Country:US
Mailing Address - Phone:580-436-7101
Mailing Address - Fax:580-436-4447
Practice Address - Street 1:2020 ARLINGTON
Practice Address - Street 2:SUITE 2
Practice Address - City:ADA
Practice Address - State:OK
Practice Address - Zip Code:74820-2822
Practice Address - Country:US
Practice Address - Phone:580-436-9037
Practice Address - Fax:580-436-9028
Is Sole Proprietor?:No
Enumeration Date:2006-09-23
Last Update Date:2014-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34008645207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology