Provider Demographics
NPI:1366939704
Name:LEACH, JORDAN NYALL (DO)
Entity type:Individual
Prefix:DR
First Name:JORDAN
Middle Name:NYALL
Last Name:LEACH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3401 W GORE BLVD
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73505-6332
Mailing Address - Country:US
Mailing Address - Phone:580-355-8620
Mailing Address - Fax:
Practice Address - Street 1:3214 E RACE AVE
Practice Address - Street 2:
Practice Address - City:SEARCY
Practice Address - State:AR
Practice Address - Zip Code:72143-4810
Practice Address - Country:US
Practice Address - Phone:435-421-1359
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-20
Last Update Date:2023-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK7413207R00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine