Healthcare Provider Details

I. General information

NPI: 1093008237
Provider Name (Legal Business Name): JORDAN J GLENN DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/20/2011
Last Update Date: 08/29/2025
Certification Date: 08/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7727 W DEER VALLEY RD STE 220
PEORIA AZ
85382-2121
US

IV. Provider business mailing address

7727 W DEER VALLEY RD STE 220
PEORIA AZ
85382-2121
US

V. Phone/Fax

Practice location:
  • Phone: 602-843-8317
  • Fax: 602-843-9091
Mailing address:
  • Phone: 602-843-8317
  • Fax: 602-843-8317

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number006890
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number006890
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code2086S0127X
TaxonomyTrauma Surgery Physician
License Number006890
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: