Provider Demographics
NPI:1720087760
Name:JORDAN, JAMES JOSEPH (MD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:JOSEPH
Last Name:JORDAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:408 SAINT PETER ST
Mailing Address - Street 2:STE 429
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55102-1119
Mailing Address - Country:US
Mailing Address - Phone:651-224-0614
Mailing Address - Fax:651-224-5754
Practice Address - Street 1:408 SAINT PETER ST
Practice Address - Street 2:STE 429
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55102-1119
Practice Address - Country:US
Practice Address - Phone:651-224-0614
Practice Address - Fax:651-224-5754
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN179622084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
107380OtherU CARE
15-10023OtherMEDICA
05975J0OtherBC/BS
A96127Medicare UPIN
15-10023OtherMEDICA