Provider Demographics
NPI:1952401002
Name:JORDAN, KERRY BRUCE (MD)
Entity Type:Individual
Prefix:DR
First Name:KERRY
Middle Name:BRUCE
Last Name:JORDAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 412554
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64141-2554
Mailing Address - Country:US
Mailing Address - Phone:913-338-4515
Mailing Address - Fax:913-338-4606
Practice Address - Street 1:11301 ASH ST
Practice Address - Street 2:
Practice Address - City:LEAWOOD
Practice Address - State:KS
Practice Address - Zip Code:66211-1643
Practice Address - Country:US
Practice Address - Phone:913-338-4515
Practice Address - Fax:913-338-4606
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2017-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-24272207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOBCBS OF KANSAS CITYOtherPROVIDER NUMBER
MOM111810Medicare ID - Type UnspecifiedPROVIDER NUMBER
MOBCBS OF KANSAS CITYOtherPROVIDER NUMBER