Healthcare Provider Details

I. General information

NPI: 1811968746
Provider Name (Legal Business Name): JAMES RANDALL JORDAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2006
Last Update Date: 01/31/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 N STATE ST DEPARTMENT OF OTOLARYNGOLOGY
JACKSON MS
39216-4500
US

IV. Provider business mailing address

2500 N STATE ST DEPARTMENT OF OTOLARYNGOLOGY
JACKSON MS
39216-4500
US

V. Phone/Fax

Practice location:
  • Phone: 601-984-5160
  • Fax: 601-815-6985
Mailing address:
  • Phone: 601-984-5160
  • Fax: 601-815-6985

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number17643
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: