Provider Demographics
NPI:1831605187
Name:JORDAN, JONATHAN
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:JORDAN
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 1:1869 PLAZA DR
Mailing Address - Street 2:
Mailing Address - City:OLEAN
Mailing Address - State:NY
Mailing Address - Zip Code:14760-1864
Mailing Address - Country:US
Mailing Address - Phone:716-373-2792
Mailing Address - Fax:716-373-2795
Practice Address - Street 1:1869 PLAZA DR
Practice Address - Street 2:
Practice Address - City:OLEAN
Practice Address - State:NY
Practice Address - Zip Code:14760-1864
Practice Address - Country:US
Practice Address - Phone:716-373-2792
Practice Address - Fax:716-373-2795
Is Sole Proprietor?:No
Enumeration Date:2017-12-22
Last Update Date:2017-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007324-1156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician