Provider Demographics
NPI:1063992444
Name:HERNDON, JORDAN (LMT)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:HERNDON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:609 W EDINBOROUGH DR
Mailing Address - Street 2:
Mailing Address - City:PALMER
Mailing Address - State:AK
Mailing Address - Zip Code:99645-6513
Mailing Address - Country:US
Mailing Address - Phone:907-521-6482
Mailing Address - Fax:
Practice Address - Street 1:7731 E NORTHERN LIGHTS BLVD STE 220
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99504-3572
Practice Address - Country:US
Practice Address - Phone:907-280-9991
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-15
Last Update Date:2018-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK121843225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK121843OtherAK LMT LICENSE