Healthcare Provider Details

I. General information

NPI: 1639005986
Provider Name (Legal Business Name): JORDAN MAX BENJAMIN PARAMEDIC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/23/2026
Last Update Date: 06/23/2026
Certification Date: 06/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2251 HOWARD ST
WALLA WALLA WA
99362-4554
US

IV. Provider business mailing address

522 36TH AVE
SAN FRANCISCO CA
94121-2608
US

V. Phone/Fax

Practice location:
  • Phone: 509-520-9150
  • Fax:
Mailing address:
  • Phone: 415-218-2211
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code146L00000X
TaxonomyParamedic
License NumberPARA.ES.60960544
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: