Provider Demographics
NPI:1861646937
Name:KEITH, JORDAN FREDERICK (OD)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:FREDERICK
Last Name:KEITH
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1202 MOORE LAKE DR E
Mailing Address - Street 2:
Mailing Address - City:FRIDLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55432-5170
Mailing Address - Country:US
Mailing Address - Phone:763-574-0075
Mailing Address - Fax:763-574-0594
Practice Address - Street 1:1202 MOORE LAKE DR E
Practice Address - Street 2:
Practice Address - City:FRIDLEY
Practice Address - State:MN
Practice Address - Zip Code:55432-5170
Practice Address - Country:US
Practice Address - Phone:763-574-0075
Practice Address - Fax:763-574-0594
Is Sole Proprietor?:No
Enumeration Date:2008-11-15
Last Update Date:2020-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3153152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist