Healthcare Provider Details

I. General information

NPI: 1275829087
Provider Name (Legal Business Name): LAUREN ELIZABETH JORDAN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/21/2011
Last Update Date: 10/25/2021
Certification Date: 10/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 W THOMAS RD ATTN: ACADEMIC AFFAIRS
PHOENIX AZ
85013-4409
US

IV. Provider business mailing address

9961 SIERRA AVE
FONTANA CA
92335-6720
US

V. Phone/Fax

Practice location:
  • Phone: 602-406-3538
  • Fax:
Mailing address:
  • Phone: 888-956-1616
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number72492
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: