Provider Demographics
NPI:1780283655
Name:WESTPHAL, JORDAN
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:WESTPHAL
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 1:1610 NW 31ST ST
Mailing Address - Street 2:
Mailing Address - City:ANKENY
Mailing Address - State:IA
Mailing Address - Zip Code:50023-4104
Mailing Address - Country:US
Mailing Address - Phone:641-430-7609
Mailing Address - Fax:
Practice Address - Street 1:4707 FLEUR DR
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50321-2335
Practice Address - Country:US
Practice Address - Phone:515-953-7413
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-22
Last Update Date:2020-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA22477183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist