Provider Demographics
NPI:1124177233
Name:JORDAN HOUSE ASSISTED LIVING, LC
Entity type:Organization
Organization Name:JORDAN HOUSE ASSISTED LIVING, LC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE ASSISTANT
Authorized Official - Prefix:MR
Authorized Official - First Name:JAUNICE
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:MINOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-269-0700
Mailing Address - Street 1:1517 TEMPLE LN
Mailing Address - Street 2:
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84095-2415
Mailing Address - Country:US
Mailing Address - Phone:801-254-0373
Mailing Address - Fax:801-254-0250
Practice Address - Street 1:1517 TEMPLE LN
Practice Address - Street 2:
Practice Address - City:SOUTH JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84095-2415
Practice Address - Country:US
Practice Address - Phone:801-254-0373
Practice Address - Fax:801-254-0250
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-09
Last Update Date:2008-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UTALII17895310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTALII17895OtherSTATE LICENSE NUMBER