Provider Demographics
NPI:1457874133
Name:JARRETT, JORDAN
Entity Type:Individual
Prefix:DR
First Name:JORDAN
Middle Name:
Last Name:JARRETT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1801 PATRIOT CIR
Mailing Address - Street 2:
Mailing Address - City:COPPERAS COVE
Mailing Address - State:TX
Mailing Address - Zip Code:76522-4437
Mailing Address - Country:US
Mailing Address - Phone:254-547-6453
Mailing Address - Fax:
Practice Address - Street 1:1801 PATRIOT CIR
Practice Address - Street 2:
Practice Address - City:COPPERAS COVE
Practice Address - State:TX
Practice Address - Zip Code:76522-4437
Practice Address - Country:US
Practice Address - Phone:254-547-6453
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-25
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX33040122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist