MEDICARE: REBECCA JOURDAN O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	60764823	WA
2	152W00000X	Optometrist	10079T	TX

General Provider Information

NPI Number	:	1710331160
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	REBECCA JOURDAN O.D.

Provider Business Mailing Address
First Line	:	4605 S COOPER ST
Second Line	:
City	:	ARLINGTON
State	:	TX
Zip	:	76017-5827
Country	:	US
Telephone Number	:	218-831-5441
Fax Number	:

Provider Business Practice Location Address
First Line	:	4605 S COOPER ST
Second Line	:
City	:	ARLINGTON
State	:	TX
Zip	:	76017-5827
Country	:	US
Telephone Number	:	817-557-9595
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/21/2016
Last Update Date	:	01/28/2021

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