Provider Demographics
NPI:1396169603
Name:BRANDON, JORDAN
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:BRANDON
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 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4829 NE MLK JR BLVD STE 101
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97211-3491
Practice Address - Country:US
Practice Address - Phone:503-283-8133
Practice Address - Fax:503-287-0245
Is Sole Proprietor?:No
Enumeration Date:2014-02-06
Last Update Date:2024-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR60454225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500668792Medicaid
ORR195466OtherMEDICARE
ORR174703Medicare PIN