Healthcare Provider Details

I. General information

NPI: 1497556526
Provider Name (Legal Business Name): JORDAN ANDREW JUSTICE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2025
Last Update Date: 06/10/2026
Certification Date: 06/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

820 HARRISON AVE FGH BUILDING 4TH FLOOR 4404
BOSTON MA
02118
US

IV. Provider business mailing address

820 HARRISON AVE FGH BUILDING 4TH FLOOR 4404
BOSTON MA
02118
US

V. Phone/Fax

Practice location:
  • Phone: 617-638-6604
  • Fax:
Mailing address:
  • Phone: 617-638-6604
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number3019856
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: