Provider Demographics
NPI:1740657857
Name:JORDAN, JIMMY
Entity type:Individual
Prefix:
First Name:JIMMY
Middle Name:
Last Name:JORDAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3507 E ADMIRAL PL
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74115-8211
Mailing Address - Country:US
Mailing Address - Phone:918-834-4194
Mailing Address - Fax:
Practice Address - Street 1:3507 E ADMIRAL PL
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74115-8211
Practice Address - Country:US
Practice Address - Phone:918-834-4194
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-24
Last Update Date:2015-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator