Healthcare Provider Details

I. General information

NPI: 1568111573
Provider Name (Legal Business Name): JORDAN VAJDA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/18/2022
Last Update Date: 05/26/2022
Certification Date: 05/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

251 E HURON ST
CHICAGO IL
60611-3055
US

IV. Provider business mailing address

251 E HURON ST
CHICAGO IL
60611-3055
US

V. Phone/Fax

Practice location:
  • Phone: 312-926-2000
  • Fax:
Mailing address:
  • Phone: 312-926-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number125079259
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: