Provider Demographics
NPI:1467039925
Name:RICHARDSON, JORDAN (DPM)
Entity type:Individual
Prefix:DR
First Name:JORDAN
Middle Name:
Last Name:RICHARDSON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17326 E BROOKS FARM RD
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85298-8805
Mailing Address - Country:US
Mailing Address - Phone:480-707-2393
Mailing Address - Fax:
Practice Address - Street 1:15810 S 45TH ST STE 190
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85048-7697
Practice Address - Country:US
Practice Address - Phone:480-378-0485
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-29
Last Update Date:2024-07-25
Deactivation Date:2021-03-29
Deactivation Code:
Reactivation Date:2021-05-03
Provider Licenses
StateLicense IDTaxonomies
AZPOD-001115213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery