Provider Demographics
NPI:1649638321
Name:WISHMYER, JORDAN
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:WISHMYER
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 1:2095 SAN JOAQUIN HILLS RD
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-6505
Mailing Address - Country:US
Mailing Address - Phone:949-500-2875
Mailing Address - Fax:949-945-0232
Practice Address - Street 1:2095 SAN JOAQUIN HILLS RD
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660
Practice Address - Country:US
Practice Address - Phone:949-500-2875
Practice Address - Fax:949-945-0232
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-09
Last Update Date:2018-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC33330111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor