Provider Demographics
NPI:1811436769
Name:LEGENDRE, JORDAN
Entity type:Individual
Prefix:MR
First Name:JORDAN
Middle Name:
Last Name:LEGENDRE
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 1:2900 WEEPING WILLOW DR
Mailing Address - Street 2:APT. I
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24501-3944
Mailing Address - Country:US
Mailing Address - Phone:503-866-1425
Mailing Address - Fax:
Practice Address - Street 1:2900 WEEPING WILLOW DRIVE
Practice Address - Street 2:APT. I
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24501
Practice Address - Country:US
Practice Address - Phone:503-866-1425
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-13
Last Update Date:2017-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program