Provider Demographics
NPI:1962856104
Name:LAKES, JORDAN TYLER (MSOT)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:TYLER
Last Name:LAKES
Suffix:
Gender:M
Credentials:MSOT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9190 PRIORITY WAY WEST DR
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46240-6426
Mailing Address - Country:US
Mailing Address - Phone:317-805-4963
Mailing Address - Fax:
Practice Address - Street 1:9190 PRIORITY WAY WEST DR
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46240-6426
Practice Address - Country:US
Practice Address - Phone:317-805-4963
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-13
Last Update Date:2016-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31006064A172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker