Provider Demographics
NPI:1912604406
Name:HUTSON, JORDON
Entity Type:Individual
Prefix:
First Name:JORDON
Middle Name:
Last Name:HUTSON
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 1:181 E NEW ENGLAND DR
Mailing Address - Street 2:
Mailing Address - City:ELKTON
Mailing Address - State:FL
Mailing Address - Zip Code:32033-4051
Mailing Address - Country:US
Mailing Address - Phone:904-501-7539
Mailing Address - Fax:
Practice Address - Street 1:1590 DUNLAWTON AVE
Practice Address - Street 2:
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32127-4752
Practice Address - Country:US
Practice Address - Phone:386-461-0191
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-14
Last Update Date:2023-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL65148183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist