Healthcare Provider Details

I. General information

NPI: 1912352659
Provider Name (Legal Business Name): JORDAN J. COHEN DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2016
Last Update Date: 06/04/2020
Certification Date: 06/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 FOULK RD STE 100B
WILMINGTON DE
19803-2764
US

IV. Provider business mailing address

1401 FOULK RD STE 100B
WILMINGTON DE
19803-2764
US

V. Phone/Fax

Practice location:
  • Phone: 302-477-3300
  • Fax: 302-477-3168
Mailing address:
  • Phone: 302-477-3300
  • Fax: 302-477-3168

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOS020283
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberC2-0013697
License Number StateDE
# 3
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberOS020283
License Number StatePA
# 4
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberC2-0013697
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: