Provider Demographics
NPI:1811047566
Name:JORDAN, JOHN S (DC)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:S
Last Name:JORDAN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 N MAIN ST STE C
Mailing Address - Street 2:
Mailing Address - City:CROWN POINT
Mailing Address - State:IN
Mailing Address - Zip Code:46307-3281
Mailing Address - Country:US
Mailing Address - Phone:219-662-7711
Mailing Address - Fax:219-662-7740
Practice Address - Street 1:300 N MAIN ST STE C
Practice Address - Street 2:
Practice Address - City:CROWN POINT
Practice Address - State:IN
Practice Address - Zip Code:46307-3281
Practice Address - Country:US
Practice Address - Phone:219-662-7711
Practice Address - Fax:219-662-7740
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-12
Last Update Date:2011-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08001394111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100147680Medicaid
IN000000184405OtherANTHEM BLUE CROSS BLUE SH
IN351875464100Medicaid
GAP00066063Medicare ID - Type UnspecifiedRAILROAD MEDICARE
IN000000184405Medicare UPIN
IN404810AMedicare ID - Type UnspecifiedINDIANA MEDICARE