Provider Demographics
NPI:1053195511
Name:JORDAN, VERNON ODELL (CHW 1)
Entity type:Individual
Prefix:
First Name:VERNON
Middle Name:ODELL
Last Name:JORDAN
Suffix:
Gender:M
Credentials:CHW 1
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11035 LAVENDER HILL DRIVE
Mailing Address - Street 2:BLDG. 160 STE. 349
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89135
Mailing Address - Country:US
Mailing Address - Phone:702-213-2007
Mailing Address - Fax:
Practice Address - Street 1:5860 S PECOS RD STE 200
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89120-5429
Practice Address - Country:US
Practice Address - Phone:702-780-1313
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-24
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVCHW1207QA0000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207QA0000XAllopathic & Osteopathic PhysiciansFamily MedicineAdolescent MedicineGroup - Multi-Specialty