Provider Demographics
NPI:1265962633
Name:GEROSKI, JORDAN (DO)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:GEROSKI
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 W JEFFERSON BLVD
Mailing Address - Street 2:STE 100
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46601-1993
Mailing Address - Country:US
Mailing Address - Phone:574-647-2624
Mailing Address - Fax:
Practice Address - Street 1:611 E DOUGLAS RD STE 137
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-1464
Practice Address - Country:US
Practice Address - Phone:574-335-6214
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-18
Last Update Date:2021-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02006037A207Q00000X, 207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN11019303AOtherSTATE LICENSE
IN300004615Medicaid