Provider Demographics
NPI:1700884897
Name:JORDAN, PATRICIA ANN (MD)
Entity Type:Individual
Prefix:DR
First Name:PATRICIA
Middle Name:ANN
Last Name:JORDAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6349 UNIVERSITY COMMONS
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46635-1475
Mailing Address - Country:US
Mailing Address - Phone:574-968-7425
Mailing Address - Fax:574-968-0390
Practice Address - Street 1:6349 UNIVERSITY COMMONS
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46635-1475
Practice Address - Country:US
Practice Address - Phone:574-968-7425
Practice Address - Fax:574-968-0390
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2010-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01033982207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200133350Medicaid
IN200133350Medicaid