Provider Demographics
NPI:1780756999
Name:GARRISON, JORDAN M (MD)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:M
Last Name:GARRISON
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:PO BOX 640
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:07109-0640
Mailing Address - Country:US
Mailing Address - Phone:973-759-8700
Mailing Address - Fax:
Practice Address - Street 1:17 NARDONE PL
Practice Address - Street 2:
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07306-3514
Practice Address - Country:US
Practice Address - Phone:201-530-1900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-14
Last Update Date:2016-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA04279600208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJE53715Medicare UPIN
NJ610838Medicare PIN