Healthcare Provider Details

I. General information

NPI: 1265369094
Provider Name (Legal Business Name): JORDAN NICOLAS CUTAIA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/06/2026
Last Update Date: 05/06/2026
Certification Date: 05/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2043 COLLEGE WAY
FOREST GROVE OR
97116-1756
US

IV. Provider business mailing address

2002 WILSON AVE APT 346
PANAMA CITY FL
32405-4863
US

V. Phone/Fax

Practice location:
  • Phone: 360-544-2399
  • Fax:
Mailing address:
  • Phone: 360-544-2399
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberSTUDENT
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: