Healthcare Provider Details

I. General information

NPI: 1528301918
Provider Name (Legal Business Name): TRESSA M JORDAN D. P. M,
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2013
Last Update Date: 02/25/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

535 MAIN ST
OLEAN NY
14760-1500
US

IV. Provider business mailing address

535 MAIN ST
OLEAN NY
14760-1500
US

V. Phone/Fax

Practice location:
  • Phone: 716-372-0141
  • Fax: 716-372-6421
Mailing address:
  • Phone: 716-372-0141
  • Fax: 716-372-6421

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number00000000
License Number StateOH

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier04498784
Identifier TypeMEDICAID
Identifier StateNY
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: