Provider Demographics
NPI:1346698529
Name:RICHARDSON, JORDAN ANNE (OD)
Entity type:Individual
Prefix:DR
First Name:JORDAN
Middle Name:ANNE
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:JORDAN
Other - Middle Name:ANNE
Other - Last Name:PINOZEK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:PO BOX 735044
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673
Mailing Address - Country:US
Mailing Address - Phone:800-326-2250
Mailing Address - Fax:
Practice Address - Street 1:700 N WESTHAVEN DR
Practice Address - Street 2:
Practice Address - City:OSHKOSH
Practice Address - State:WI
Practice Address - Zip Code:54904
Practice Address - Country:US
Practice Address - Phone:920-303-8700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-29
Last Update Date:2024-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3961-35152W00000X
CA34181152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100293138Medicaid