Healthcare Provider Details

I. General information

NPI: 1043321276
Provider Name (Legal Business Name): GLENN DAVIS JORDAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

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

315 MARTIN LUTHER KING JR WAY MS Z0 NTL
TACOMA WA
98405-4234
US

IV. Provider business mailing address

8 33RD AVENUE CT NW
GIG HARBOR WA
98335-7849
US

V. Phone/Fax

Practice location:
  • Phone: 253-403-1019
  • Fax:
Mailing address:
  • Phone: 253-403-1019
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License NumberMD00025749
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: