Provider Demographics
NPI:1245696087
Name:MARTIN, JORDAN BRADLEY (DC)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:BRADLEY
Last Name:MARTIN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 S ALTA MIRA RD
Mailing Address - Street 2:
Mailing Address - City:LAGUNA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92651-6713
Mailing Address - Country:US
Mailing Address - Phone:949-291-5720
Mailing Address - Fax:
Practice Address - Street 1:330 PARK AVE STE 3
Practice Address - Street 2:
Practice Address - City:LAGUNA BEACH
Practice Address - State:CA
Practice Address - Zip Code:92651-2352
Practice Address - Country:US
Practice Address - Phone:949-497-2553
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-09
Last Update Date:2016-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA33451111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor