Provider Demographics
NPI:1841767712
Name:WURST-SMITH, JORDON ALEXANDER
Entity Type:Individual
Prefix:
First Name:JORDON
Middle Name:ALEXANDER
Last Name:WURST-SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:JORDON
Other - Middle Name:ALEXANDER
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:44 INDIANA AVE NW
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49504-6369
Mailing Address - Country:US
Mailing Address - Phone:616-333-9116
Mailing Address - Fax:
Practice Address - Street 1:44 INDIANA AVE NW
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49504-6369
Practice Address - Country:US
Practice Address - Phone:616-333-9116
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-30
Last Update Date:2018-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program