Provider Demographics
NPI:1881075570
Name:ADAMS, JORDAN BLAKE (DO)
Entity type:Individual
Prefix:MR
First Name:JORDAN
Middle Name:BLAKE
Last Name:ADAMS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:750 MORTON BLVD
Mailing Address - Street 2:
Mailing Address - City:HAZARD
Mailing Address - State:KY
Mailing Address - Zip Code:41701-9469
Mailing Address - Country:US
Mailing Address - Phone:606-439-1559
Mailing Address - Fax:606-436-6988
Practice Address - Street 1:750 MORTON BLVD
Practice Address - Street 2:
Practice Address - City:HAZARD
Practice Address - State:KY
Practice Address - Zip Code:41701-5002
Practice Address - Country:US
Practice Address - Phone:606-439-1559
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-18
Last Update Date:2021-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC52111207Q00000X
KY04299207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC521117Medicaid
SCSCE2356067OtherMEDICARE PIN
SCSCE235J577OtherMEDICARE PIN
SCSCE2356084OtherMEDICARE PIN