Healthcare Provider Details

I. General information

NPI: 1215695911
Provider Name (Legal Business Name): JORDAN MCNALLY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/30/2021
Last Update Date: 11/30/2021
Certification Date: 11/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

62855 DANIEL RD
BEND OR
97701-9563
US

IV. Provider business mailing address

2480 NE TWIN KNOLLS DR
BEND OR
97701-6833
US

V. Phone/Fax

Practice location:
  • Phone: 513-908-7311
  • Fax:
Mailing address:
  • Phone: 541-323-7552
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VII. Legacy identifiers

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: