Provider Demographics
NPI:1801935044
Name:JORDAN, KENNETH MICHAEL (OWNER)
Entity type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:MICHAEL
Last Name:JORDAN
Suffix:
Gender:M
Credentials:OWNER
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 173248
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76003-3248
Mailing Address - Country:US
Mailing Address - Phone:817-507-0185
Mailing Address - Fax:817-507-2190
Practice Address - Street 1:4201 E LOOP 820 S
Practice Address - Street 2:STE C
Practice Address - City:FT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76119-4443
Practice Address - Country:US
Practice Address - Phone:817-507-0185
Practice Address - Fax:817-507-2190
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TX03040415892471C3402X
TX2471S1302X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered2471C3402XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistRadiography
Not Answered2471S1302XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistSonography