Healthcare Provider Details

I. General information

NPI: 1053195511
Provider Name (Legal Business Name): VERNON ODELL JORDAN CHW 1
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/24/2023
Last Update Date: 08/24/2023
Certification Date: 08/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5860 S PECOS RD STE 200
LAS VEGAS NV
89120-5429
US

IV. Provider business mailing address

11035 LAVENDER HILL DRIVE BLDG. 160 STE. 349
LAS VEGAS NV
89135
US

V. Phone/Fax

Practice location:
  • Phone: 702-780-1313
  • Fax:
Mailing address:
  • Phone: 702-213-2007
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0000X
TaxonomyAdolescent Medicine (Family Medicine) Physician
License NumberCHW1
License Number StateNV
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberCHW1
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: