Provider Demographics
NPI:1932060381
Name:ANDERSON, JORDON DALTON
Entity type:Individual
Prefix:
First Name:JORDON
Middle Name:DALTON
Last Name:ANDERSON
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 1:2106 FOUNTAIN CREEK DR APT A
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MO
Mailing Address - Zip Code:64504-1884
Mailing Address - Country:US
Mailing Address - Phone:816-344-6896
Mailing Address - Fax:
Practice Address - Street 1:2106 FOUNTAIN CREEK DR APT A
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MO
Practice Address - Zip Code:64504-1884
Practice Address - Country:US
Practice Address - Phone:816-344-6896
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-11-24
Last Update Date:2025-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program