Healthcare Provider Details

I. General information

NPI: 1447385950
Provider Name (Legal Business Name): JERRY J. JORDAN ED.D., CTRS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/23/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 DONNA AVE
GUTHRIE OK
73044-9494
US

IV. Provider business mailing address

325 DONNA AVE
GUTHRIE OK
73044-9494
US

V. Phone/Fax

Practice location:
  • Phone: 405-744-9424
  • Fax: 405-744-6507
Mailing address:
  • Phone: 405-744-9424
  • Fax: 405-744-6507

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225800000X
TaxonomyRecreation Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: