Provider Demographics
NPI:1083294771
Name:JORDAN, BRIA MAXINE
Entity type:Individual
Prefix:
First Name:BRIA
Middle Name:MAXINE
Last Name:JORDAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7037 S STONY ISLAND AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60649-1905
Mailing Address - Country:US
Mailing Address - Phone:312-355-5590
Mailing Address - Fax:312-355-5571
Practice Address - Street 1:7037 S STONY ISLAND AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60649-1905
Practice Address - Country:US
Practice Address - Phone:312-996-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-08
Last Update Date:2024-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.17937207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine