Provider Demographics
NPI:1255134961
Name:SULLIVAN, JORDAN PATRICK
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:PATRICK
Last Name:SULLIVAN
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5720 AMES BLVD
Mailing Address - Street 2:
Mailing Address - City:MARRERO
Mailing Address - State:LA
Mailing Address - Zip Code:70072-6627
Mailing Address - Country:US
Mailing Address - Phone:504-347-3555
Mailing Address - Fax:
Practice Address - Street 1:1000 BLYTHE BLVD STE 601
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28203-5812
Practice Address - Country:US
Practice Address - Phone:704-355-7874
Practice Address - Fax:704-355-5619
Is Sole Proprietor?:No
Enumeration Date:2025-03-28
Last Update Date:2025-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program