Healthcare Provider Details

I. General information

NPI: 1366105843
Provider Name (Legal Business Name): MR. JORDAN BRYAN HURTADO SR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/20/2021
Last Update Date: 05/23/2022
Certification Date: 05/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 W MAGNOLIA AVE
LONGWOOD FL
32750-4130
US

IV. Provider business mailing address

111 W MAGNOLIA AVE
LONGWOOD FL
32750-4130
US

V. Phone/Fax

Practice location:
  • Phone: 407-215-0095
  • Fax:
Mailing address:
  • Phone: 407-215-0095
  • 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: