Basic Information
| Provider Information | |||||||||
| NPI: | 1962451294 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JORDON | ||||||||
| FirstName: | RENIE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M. D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 421 MARION AVE | ||||||||
| Address2: | |||||||||
| City: | MCCOMB | ||||||||
| State: | MS | ||||||||
| PostalCode: | 396482709 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6016846891 | ||||||||
| FaxNumber: | 6012493834 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 RAWLS DR STE 600 | ||||||||
| Address2: | |||||||||
| City: | MCCOMB | ||||||||
| State: | MS | ||||||||
| PostalCode: | 396482862 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6012494415 | ||||||||
| FaxNumber: | 6012494474 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/05/2006 | ||||||||
| LastUpdateDate: | 12/14/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 14640 | MS | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00116649 | 05 | MS | MEDICAID |