Healthcare Provider Details

I. General information

NPI: 1740778430
Provider Name (Legal Business Name): JORDAN CHASE ILIC PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2018
Last Update Date: 04/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3050 WILMA RUDOLPH BLVD
CLARKSVILLE TN
37040-5031
US

IV. Provider business mailing address

3050 WILMA RUDOLPH BLVD
CLARKSVILLE TN
37040-5031
US

V. Phone/Fax

Practice location:
  • Phone: 931-552-0241
  • Fax:
Mailing address:
  • Phone: 931-552-0241
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number17214
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number38240
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: