Provider Demographics
NPI:1699508820
Name:JORDAN, ANTHONY JEROME
Entity type:Individual
Prefix:
First Name:ANTHONY
Middle Name:JEROME
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 1:604 W 4TH ST
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92410-3216
Mailing Address - Country:US
Mailing Address - Phone:909-701-7223
Mailing Address - Fax:
Practice Address - Street 1:604 W 4TH ST
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92410-3216
Practice Address - Country:US
Practice Address - Phone:909-701-7223
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-22
Last Update Date:2024-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker