Healthcare Provider Details

I. General information

NPI: 1598394975
Provider Name (Legal Business Name): JORDAN KNOPPERT IDC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2020
Last Update Date: 04/07/2020
Certification Date: 04/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1498 13TH STREET NOLF BLDG 193
IMPERIAL BEACH CA
91932-3798
US

IV. Provider business mailing address

1390 SANTA ALICIA AVE APT 9204
CHULA VISTA CA
91913-1857
US

V. Phone/Fax

Practice location:
  • Phone: 619-437-9845
  • Fax:
Mailing address:
  • Phone: 631-609-0679
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: