Provider Demographics
NPI:1699278572
Name:VAN DE VELDE, JORDON (DO)
Entity type:Individual
Prefix:
First Name:JORDON
Middle Name:
Last Name:VAN DE VELDE
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 1:2214 E 29TH AVE
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99203-3939
Mailing Address - Country:US
Mailing Address - Phone:509-755-5250
Mailing Address - Fax:509-755-5251
Practice Address - Street 1:2214 E 29TH AVE
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99203-3939
Practice Address - Country:US
Practice Address - Phone:509-755-5250
Practice Address - Fax:509-755-5251
Is Sole Proprietor?:No
Enumeration Date:2018-03-16
Last Update Date:2023-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61141566207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA61141566OtherWASHINGTON STATE DEPARTMENT OF HEALTH