Healthcare Provider Details

I. General information

NPI: 1083060396
Provider Name (Legal Business Name): KELLY JORDAN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/05/2016
Last Update Date: 12/20/2022
Certification Date: 12/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

747 52ND ST
OAKLAND CA
94609-1809
US

IV. Provider business mailing address

3261 FRANKLIN AVE E APT 7
SEATTLE WA
98102-3858
US

V. Phone/Fax

Practice location:
  • Phone: 510-428-3331
  • Fax:
Mailing address:
  • Phone: 949-981-0626
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD60945855
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License Number333542
License Number StateLA
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License NumberMD60945855
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: