Healthcare Provider Details

I. General information

NPI: 1821179029
Provider Name (Legal Business Name): JAMES L. JORDAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 10/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

331 HOSPITAL DR SUITE D
LEBANON MO
65536-9217
US

IV. Provider business mailing address

PO BOX 505164
SAINT LOUIS MO
63150-5164
US

V. Phone/Fax

Practice location:
  • Phone: 417-532-3495
  • Fax: 417-532-3598
Mailing address:
  • Phone: 417-829-4620
  • Fax: 417-829-4316

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License Number2000160358
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: