MEDICARE: MR. KENNETH MICHAEL JORDAN OWNER

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	2471C3402X	Radiography Radiologic Technologist	0304041589	TX
2	2471S1302X	Sonography Radiologic Technologist		TX

General Provider Information

NPI Number	:	1801935044
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. KENNETH MICHAEL JORDAN OWNER

Provider Business Mailing Address
First Line	:	PO BOX 173248
Second Line	:
City	:	ARLINGTON
State	:	TX
Zip	:	76003-3248
Country	:	US
Telephone Number	:	817-507-0185
Fax Number	:	817-507-2190

Provider Business Practice Location Address
First Line	:	4201 E LOOP 820 S
Second Line	:	STE C
City	:	FT WORTH
State	:	TX
Zip	:	76119-4443
Country	:	US
Telephone Number	:	817-507-0185
Fax Number	:	817-507-2190

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

Provider Enumeration Date	:	02/05/2007
Last Update Date	:	09/11/2025

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