Healthcare Provider Details

I. General information

NPI: 1356210926
Provider Name (Legal Business Name): JORDAN REID MUDD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/03/2025
Last Update Date: 11/07/2025
Certification Date: 11/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2022 BATTERY PARK DR
GLENDALE KY
42740-8800
US

IV. Provider business mailing address

2910 SHREWSBURY RD
LEITCHFIELD KY
42754-8227
US

V. Phone/Fax

Practice location:
  • Phone: 859-314-3670
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WX0106X
TaxonomyOccupational Health Registered Nurse
License Number1141347
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: