Healthcare Provider Details

I. General information

NPI: 1912347675
Provider Name (Legal Business Name): JORDAN JAMES ALLENSWORTH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2013
Last Update Date: 07/16/2021
Certification Date: 07/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

417 SE 164TH AVE STE 300
VANCOUVER WA
98684-8944
US

IV. Provider business mailing address

3181 SW SAM JACKSON PARK RD OHSU
PORTLAND OR
97239-3011
US

V. Phone/Fax

Practice location:
  • Phone: 360-256-4425
  • Fax: 360-256-2474
Mailing address:
  • Phone: 503-494-8220
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberMD61144936
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: