Provider Demographics
NPI:1366325649
Name:SAMUEL, JORDAN
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:SAMUEL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2291 LALIQUE CIR
Mailing Address - Street 2:
Mailing Address - City:COLTON
Mailing Address - State:CA
Mailing Address - Zip Code:92324-9242
Mailing Address - Country:US
Mailing Address - Phone:901-734-3464
Mailing Address - Fax:
Practice Address - Street 1:2291 LALIQUE CIR
Practice Address - Street 2:
Practice Address - City:COLTON
Practice Address - State:CA
Practice Address - Zip Code:92324-9242
Practice Address - Country:US
Practice Address - Phone:901-734-3464
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-26
Last Update Date:2025-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program