Provider Demographics
NPI:1790107134
Name:JORDAN, DEANDRE
Entity Type:Individual
Prefix:
First Name:DEANDRE
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 1:4965 ATHENS BAY PL
Mailing Address - Street 2:
Mailing Address - City:N LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89031-0971
Mailing Address - Country:US
Mailing Address - Phone:702-817-3094
Mailing Address - Fax:
Practice Address - Street 1:3690 N RANCHO DR
Practice Address - Street 2:3692 N. RANCHO DR.
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89130-3182
Practice Address - Country:US
Practice Address - Phone:702-749-6263
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-18
Last Update Date:2014-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV225400000XMedicaid