Provider Demographics
NPI:1043321276
Name:JORDAN, GLENN DAVIS (MD)
Entity type:Individual
Prefix:DR
First Name:GLENN
Middle Name:DAVIS
Last Name:JORDAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:8 33RD AVENUE CT NW
Mailing Address - Street 2:
Mailing Address - City:GIG HARBOR
Mailing Address - State:WA
Mailing Address - Zip Code:98335-7849
Mailing Address - Country:US
Mailing Address - Phone:253-403-1019
Mailing Address - Fax:
Practice Address - Street 1:315 MARTIN LUTHER KING JR WAY
Practice Address - Street 2:MS Z0 NTL
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-4234
Practice Address - Country:US
Practice Address - Phone:253-403-1019
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD000257492080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine