MEDICARE: JORDAN BERRY

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	124Q00000X	Dental Hygienist	2015016912	MO

General Provider Information

NPI Number	:	1891145975
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JORDAN BERRY

Provider Business Mailing Address
First Line	:	1416 CROWN DR
Second Line	:
City	:	KIRKSVILLE
State	:	MO
Zip	:	63501-2548
Country	:	US
Telephone Number	:	660-627-5757
Fax Number	:

Provider Business Practice Location Address
First Line	:	209 N MISSOURI ST
Second Line	:
City	:	MACON
State	:	MO
Zip	:	63552-2151
Country	:	US
Telephone Number	:	660-395-5045
Fax Number	:

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

Provider Enumeration Date	:	06/20/2016
Last Update Date	:	06/20/2016

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Directions to “ JORDAN BERRY ” Practice Location

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