Healthcare Provider Details

I. General information

NPI: 1740108737
Provider Name (Legal Business Name): JOHN JORDAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/07/2026
Last Update Date: 07/07/2026
Certification Date: 07/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PO BOX 1714
BOULDER CO
80306-1714
US

IV. Provider business mailing address

PO BOX 1714
BOULDER CO
80306-1714
US

V. Phone/Fax

Practice location:
  • Phone: 720-258-6090
  • Fax:
Mailing address:
  • Phone: 720-258-6090
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: