Provider Demographics
NPI:1811405178
Name:HURST, JORDAN
Entity Type:Individual
Prefix:MR
First Name:JORDAN
Middle Name:
Last Name:HURST
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 1:707 N STORY AVE
Mailing Address - Street 2:
Mailing Address - City:WAGONER
Mailing Address - State:OK
Mailing Address - Zip Code:74467-2943
Mailing Address - Country:US
Mailing Address - Phone:918-485-4046
Mailing Address - Fax:
Practice Address - Street 1:500 BULLDOG CIR
Practice Address - Street 2:
Practice Address - City:WAGONER
Practice Address - State:OK
Practice Address - Zip Code:74467-4522
Practice Address - Country:US
Practice Address - Phone:918-485-4046
Practice Address - Fax:918-485-8710
Is Sole Proprietor?:No
Enumeration Date:2018-01-19
Last Update Date:2018-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant