Provider Demographics
NPI:1861038895
Name:ROBERTSON, JORDAN (DC)
Entity Type:Individual
Prefix:DR
First Name:JORDAN
Middle Name:
Last Name:ROBERTSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6434 W INTERCHANGE LN
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83709-2123
Mailing Address - Country:US
Mailing Address - Phone:208-322-7755
Mailing Address - Fax:
Practice Address - Street 1:6434 W INTERCHANGE LN
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83709-2123
Practice Address - Country:US
Practice Address - Phone:208-322-7755
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-25
Last Update Date:2019-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA-1973111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor