Provider Demographics
NPI:1861197725
Name:NASENBENY, JORDAN ANDREW (MD, MSC)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:ANDREW
Last Name:NASENBENY
Suffix:
Gender:M
Credentials:MD, MSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 NE MADISON AVE APT G
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61603-5805
Mailing Address - Country:US
Mailing Address - Phone:847-310-5673
Mailing Address - Fax:
Practice Address - Street 1:900 MAIN ST STE 720
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61602-5027
Practice Address - Country:US
Practice Address - Phone:309-671-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-31
Last Update Date:2023-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL390200000X390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program