Basic Information
| Provider Information | |||||||||
| NPI: | 1073142832 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MADDOX | ||||||||
| FirstName: | JORDAN | ||||||||
| MiddleName: | ALEXANDER | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4956 N WESTERN AVE APT 1S | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606256884 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8473456688 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 7301 E 2ND ST STE 210 | ||||||||
| Address2: | |||||||||
| City: | SCOTTSDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852515620 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4808824545 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/03/2020 | ||||||||
| LastUpdateDate: | 04/03/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.