Provider Demographics
NPI:1891359634
Name:JORDAN, JOHNNY LEE
Entity Type:Individual
Prefix:
First Name:JOHNNY
Middle Name:LEE
Last Name:JORDAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4032 M 139 STE 108
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085-8664
Mailing Address - Country:US
Mailing Address - Phone:269-556-1526
Mailing Address - Fax:
Practice Address - Street 1:4032 M 139 STE 108
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085-8664
Practice Address - Country:US
Practice Address - Phone:269-556-1526
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-26
Last Update Date:2019-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist