Provider Demographics
NPI:1831792837
Name:JORDAN, TY
Entity type:Individual
Prefix:
First Name:TY
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:RR 1 BOX 192
Mailing Address - Street 2:
Mailing Address - City:BREMEN
Mailing Address - State:OH
Mailing Address - Zip Code:43107-9103
Mailing Address - Country:US
Mailing Address - Phone:614-332-7893
Mailing Address - Fax:
Practice Address - Street 1:921 W FAIR AVE
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:OH
Practice Address - Zip Code:43130-2348
Practice Address - Country:US
Practice Address - Phone:614-332-7893
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-20
Last Update Date:2020-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care