Provider Demographics
NPI:1528301918
Name:JORDAN, TRESSA M (D P M,)
Entity type:Individual
Prefix:
First Name:TRESSA
Middle Name:M
Last Name:JORDAN
Suffix:
Gender:F
Credentials:D P M,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:535 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:OLEAN
Mailing Address - State:NY
Mailing Address - Zip Code:14760-1500
Mailing Address - Country:US
Mailing Address - Phone:716-372-0141
Mailing Address - Fax:716-372-6421
Practice Address - Street 1:535 MAIN ST
Practice Address - Street 2:
Practice Address - City:OLEAN
Practice Address - State:NY
Practice Address - Zip Code:14760-1500
Practice Address - Country:US
Practice Address - Phone:716-372-0141
Practice Address - Fax:716-372-6421
Is Sole Proprietor?:No
Enumeration Date:2013-04-03
Last Update Date:2022-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH00000000213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04498784Medicaid
NYJ400340226Medicare PIN