Provider Demographics
NPI:1972659647
Name:JORDAN, JANEEN RENE (MD)
Entity Type:Individual
Prefix:
First Name:JANEEN
Middle Name:RENE
Last Name:JORDAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 100108
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32610-0108
Mailing Address - Country:US
Mailing Address - Phone:352-273-5670
Mailing Address - Fax:352-273-5683
Practice Address - Street 1:311 N CLYDE MORRIS BLVD STE 510
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-2757
Practice Address - Country:US
Practice Address - Phone:386-241-1020
Practice Address - Fax:386-241-1022
Is Sole Proprietor?:No
Enumeration Date:2007-01-26
Last Update Date:2022-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME112412208600000X, 2086S0102X
COTL-877390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
No208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLGG480ZMedicare PIN