Healthcare Provider Details

I. General information

NPI: 1962856104
Provider Name (Legal Business Name): JORDAN TYLER LAKES MSOT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/13/2016
Last Update Date: 04/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9190 PRIORITY WAY WEST DR
INDIANAPOLIS IN
46240-6426
US

IV. Provider business mailing address

9190 PRIORITY WAY WEST DR
INDIANAPOLIS IN
46240-6426
US

V. Phone/Fax

Practice location:
  • Phone: 317-805-4963
  • Fax:
Mailing address:
  • Phone: 317-805-4963
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number31006064A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: