MEDICARE: JORDAN FREDERICK KEITH 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	3153	MN
2	152W00000X	Optometrist	1589	NE
3	152W00000X	Optometrist	116516	IA

General Provider Information

NPI Number	:	1861646937
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JORDAN FREDERICK KEITH O.D.

Provider Business Mailing Address
First Line	:	3606 N 156TH ST STE 105
Second Line	:
City	:	OMAHA
State	:	NE
Zip	:	68116-2163
Country	:	US
Telephone Number	:	402-205-0754
Fax Number	:

Provider Business Practice Location Address
First Line	:	3606 N 156TH ST
Second Line	:
City	:	OMAHA
State	:	NE
Zip	:	68116-2158
Country	:	US
Telephone Number	:	402-205-0754
Fax Number	:

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

Provider Enumeration Date	:	11/15/2008
Last Update Date	:	09/12/2025

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