Provider Demographics
NPI:1457934069
Name:STROUD, JORDAN LEAH (DO)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:LEAH
Last Name:STROUD
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1275 DICK LONAS RD UNIT 101
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37909-1383
Mailing Address - Country:US
Mailing Address - Phone:865-584-4747
Mailing Address - Fax:865-381-1509
Practice Address - Street 1:1341 BRANTON BLVD STE 102
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37922-8521
Practice Address - Country:US
Practice Address - Phone:656-887-7704
Practice Address - Fax:865-591-4894
Is Sole Proprietor?:No
Enumeration Date:2021-05-01
Last Update Date:2024-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TN5695208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program