Provider Demographics
NPI:1396905998
Name:PRENDERGAST, JORDAN MYERS (DO)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:MYERS
Last Name:PRENDERGAST
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 1:630 SOUTHPOINT DR
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40515-6350
Mailing Address - Country:US
Mailing Address - Phone:859-272-1928
Mailing Address - Fax:859-271-9601
Practice Address - Street 1:630 SOUTHPOINT DR
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40515-6350
Practice Address - Country:US
Practice Address - Phone:859-272-1928
Practice Address - Fax:859-271-9601
Is Sole Proprietor?:No
Enumeration Date:2008-06-17
Last Update Date:2016-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY03156207Q00000X
KYR1335207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYR1335OtherKENTUCKY STATE LICENSE
KY03156OtherKY LICENSE
KY0169Medicare PIN