Provider Demographics
NPI:1427345784
Name:JORDAN, JEREMY
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:JORDAN
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 1:1705 DELHI ST
Mailing Address - Street 2:LOWER LEVEL
Mailing Address - City:DUBUQUE
Mailing Address - State:IA
Mailing Address - Zip Code:52001-5900
Mailing Address - Country:US
Mailing Address - Phone:563-582-4170
Mailing Address - Fax:563-582-4181
Practice Address - Street 1:1705 DELHI ST
Practice Address - Street 2:LOWER LEVEL
Practice Address - City:DUBUQUE
Practice Address - State:IA
Practice Address - Zip Code:52001-5900
Practice Address - Country:US
Practice Address - Phone:563-582-4170
Practice Address - Fax:563-582-4181
Is Sole Proprietor?:No
Enumeration Date:2011-07-06
Last Update Date:2011-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA004752225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1609052323OtherGROUP NPI #