Provider Demographics
NPI:1205290350
Name:ROUSSEL, JORDAN MICHAEL (MD)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:MICHAEL
Last Name:ROUSSEL
Suffix:
Gender:M
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 1810
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39502
Mailing Address - Country:US
Mailing Address - Phone:228-575-1194
Mailing Address - Fax:228-575-2917
Practice Address - Street 1:14209 COOK RD
Practice Address - Street 2:SUITE 200
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39532
Practice Address - Country:US
Practice Address - Phone:228-867-4150
Practice Address - Fax:228-875-9558
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-05
Last Update Date:2023-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS29976207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology