Provider Demographics
NPI:1871638718
Name:JORDAN, JOHN M (DC)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:M
Last Name:JORDAN
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 1:438 N WATER ST
Mailing Address - Street 2:
Mailing Address - City:BLACK RIVER FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54615-1005
Mailing Address - Country:US
Mailing Address - Phone:171-528-4555
Mailing Address - Fax:171-528-4916
Practice Address - Street 1:438 N WATER ST
Practice Address - Street 2:
Practice Address - City:BLACK RIVER FALLS
Practice Address - State:WI
Practice Address - Zip Code:54615-1005
Practice Address - Country:US
Practice Address - Phone:171-528-4555
Practice Address - Fax:171-528-4916
Is Sole Proprietor?:No
Enumeration Date:2007-02-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2413111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38992500Medicaid