Provider Demographics
NPI:1942873807
Name:JORDAN, DEREK JOSEPH
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:JOSEPH
Last Name:JORDAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:DEREK
Other - Middle Name:J
Other - Last Name:JORDAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:517 32ND ST APT 25
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98225-6536
Mailing Address - Country:US
Mailing Address - Phone:509-871-0859
Mailing Address - Fax:
Practice Address - Street 1:517 32ND ST APT 25
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225-6536
Practice Address - Country:US
Practice Address - Phone:509-871-0859
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-20
Last Update Date:2021-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program