Provider Demographics
NPI:1790222198
Name:GREGORY, JORDAN
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:GREGORY
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 1:3065 DAVE WARD DR APT 213
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72034-9411
Mailing Address - Country:US
Mailing Address - Phone:479-831-3177
Mailing Address - Fax:
Practice Address - Street 1:3065 DAVE WARD DR APT 213
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72034-9411
Practice Address - Country:US
Practice Address - Phone:479-831-3177
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-23
Last Update Date:2017-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program