Healthcare Provider Details

I. General information

NPI: 1104938372
Provider Name (Legal Business Name): JORDEN BRENT WEISS JORDEN WEISS D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5965 E BROAD ST
COLUMBUS OH
43213-1562
US

IV. Provider business mailing address

5965 E. BROAD STREET
COLUMBUS OH
43213
US

V. Phone/Fax

Practice location:
  • Phone: 614-759-5075
  • Fax: 614-759-5079
Mailing address:
  • Phone: 614-759-5075
  • Fax: 614-759-5079

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number34006906W
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: