Healthcare Provider Details

I. General information

NPI: 1568359529
Provider Name (Legal Business Name): JORDAN GREEN OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2025
Last Update Date: 12/04/2025
Certification Date: 12/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1545 ADAMS AVE STE 100
COSTA MESA CA
92626-3875
US

IV. Provider business mailing address

34 LYON RDG
ALISO VIEJO CA
92656-5279
US

V. Phone/Fax

Practice location:
  • Phone: 714-545-9162
  • Fax: 714-241-1345
Mailing address:
  • Phone:
  • Fax: 714-241-1345

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number36035
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: