Provider Demographics
NPI:1750781282
Name:LONG, JORDAN MICHELLE (DC)
Entity type:Individual
Prefix:DR
First Name:JORDAN
Middle Name:MICHELLE
Last Name:LONG
Suffix:
Gender:F
Credentials:DC
Other - Prefix:DR
Other - First Name:JORDAN
Other - Middle Name:MICHELLE
Other - Last Name:LONG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DC
Mailing Address - Street 1:2140 NORCOR AVE
Mailing Address - Street 2:SUITE D
Mailing Address - City:CORALVILLE
Mailing Address - State:IA
Mailing Address - Zip Code:52241-9736
Mailing Address - Country:US
Mailing Address - Phone:319-354-4186
Mailing Address - Fax:
Practice Address - Street 1:2140 NORCOR AVE
Practice Address - Street 2:SUITE D
Practice Address - City:CORALVILLE
Practice Address - State:IA
Practice Address - Zip Code:52241-9736
Practice Address - Country:US
Practice Address - Phone:319-354-4186
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-03
Last Update Date:2015-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA007733111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor