Provider Demographics
NPI:1801408604
Name:HOLDER, JORDAN LEIGH
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:LEIGH
Last Name:HOLDER
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 1:225 FOXCROFT RD
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:44904-9725
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11109 PARKVIEW PLAZA DR # 1
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-1701
Practice Address - Country:US
Practice Address - Phone:260-266-3080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-21
Last Update Date:2020-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26028699A183500000X
OH03439309183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH03439309OtherOHIO PHARMACIST LICENSE
IN26028699AOtherINDIANA PHARMACY LICENSE