Healthcare Provider Details

I. General information

NPI: 1174894281
Provider Name (Legal Business Name): JORDAN GLIEDT D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/20/2012
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1155 N MAYFAIR RD
MILWAUKEE WI
53226-3462
US

IV. Provider business mailing address

1155 N MAYFAIR RD
MILWAUKEE WI
53226-3462
US

V. Phone/Fax

Practice location:
  • Phone: 414-955-7199
  • Fax: 414-955-0110
Mailing address:
  • Phone: 414-955-7199
  • Fax: 414-955-0110

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number15955
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number5300
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: