Healthcare Provider Details

I. General information

NPI: 1356803753
Provider Name (Legal Business Name): JORDAN BAKER DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2019
Last Update Date: 08/02/2023
Certification Date: 08/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

975 S FAIRMONT AVE
LODI CA
95240-5118
US

IV. Provider business mailing address

1163 E. MARCH LANE SUITE D #366
STOCKTON CA
95210-4512
US

V. Phone/Fax

Practice location:
  • Phone: 209-334-3411
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number20A19373
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: