Provider Demographics
NPI:1699521054
Name:MCDONALD-JORDAN, CARLTON
Entity type:Individual
Prefix:
First Name:CARLTON
Middle Name:
Last Name:MCDONALD-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 1:1008 S 9TH ST
Mailing Address - Street 2:
Mailing Address - City:POPLAR BLUFF
Mailing Address - State:MO
Mailing Address - Zip Code:63901-6256
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 COLLEGE PARK DR
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8660
Practice Address - Country:US
Practice Address - Phone:573-300-8828
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-26
Last Update Date:2024-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer