MEDICARE: JORDAN HENDERSON M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207L00000X	Anesthesiology Physician	11443143-1205	UT

General Provider Information

NPI Number	:	1710391107
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JORDAN HENDERSON M.D.

Provider Business Mailing Address
First Line	:	30 N 1900 E RM 3C444
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84132-2501
Country	:	US
Telephone Number	:	801-581-3622
Fax Number	:

Provider Business Practice Location Address
First Line	:	30 N 1900 E RM 3C444
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84132-2501
Country	:	US
Telephone Number	:	801-581-3622
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/13/2014
Last Update Date	:	11/03/2021

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