Healthcare Provider Details

I. General information

NPI: 1043802937
Provider Name (Legal Business Name): KATHLEEN JORDAN MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/11/2021
Last Update Date: 03/24/2023
Certification Date: 03/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3921 W. SUNSET BOULEVARD
LOS ANGELES CA
90029
US

IV. Provider business mailing address

30 E 23RD ST STE 700
NEW YORK NY
10010-4408
US

V. Phone/Fax

Practice location:
  • Phone: 646-650-5337
  • Fax:
Mailing address:
  • Phone: 332-203-0933
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number
License Number State

VIII. Authorized Official

Name: CHANAH SHELDON
Title or Position: PAYER RELATIONS MANAGER
Credential:
Phone: 503-887-5519