Provider Demographics
NPI:1619709805
Name:SANDERS, JORDAN DOUGLAS (AG-ACNP)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:DOUGLAS
Last Name:SANDERS
Suffix:
Gender:M
Credentials:AG-ACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3231 ORCUTT RD APT 3
Mailing Address - Street 2:
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93455-2396
Mailing Address - Country:US
Mailing Address - Phone:325-668-7031
Mailing Address - Fax:
Practice Address - Street 1:1900 PINE ST
Practice Address - Street 2:
Practice Address - City:ABILENE
Practice Address - State:TX
Practice Address - Zip Code:79601-2432
Practice Address - Country:US
Practice Address - Phone:412-371-9133
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-15
Last Update Date:2024-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95211424163WC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine