Provider Demographics
NPI:1821104290
Name:WHITE, JORDAN C (MD)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:C
Last Name:WHITE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 BREWSTER STREET
Mailing Address - Street 2:WOOD BLDG #516
Mailing Address - City:PAWTUCKET
Mailing Address - State:RI
Mailing Address - Zip Code:02860-4474
Mailing Address - Country:US
Mailing Address - Phone:401-729-3481
Mailing Address - Fax:401-729-2721
Practice Address - Street 1:1000 BROAD STREET
Practice Address - Street 2:
Practice Address - City:CENTRAL FALLS
Practice Address - State:RI
Practice Address - Zip Code:02863-1507
Practice Address - Country:US
Practice Address - Phone:401-726-1800
Practice Address - Fax:401-727-3556
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2011-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RILP00927207Q00000X
MA239888207Q00000X
RIMD13569207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIJW88517Medicaid