Provider Demographics
NPI:1174151575
Name:BROADWAY, JORDAN
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:BROADWAY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2213 ELBA STREET DUMC 3837 ROOM 272A
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27710-0001
Mailing Address - Country:US
Mailing Address - Phone:919-684-8785
Mailing Address - Fax:919-684-2290
Practice Address - Street 1:2213 ELBA STREET DUMC 3837 ROOM 272A
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27710-0001
Practice Address - Country:US
Practice Address - Phone:919-684-8785
Practice Address - Fax:919-684-2290
Is Sole Proprietor?:No
Enumeration Date:2020-03-31
Last Update Date:2020-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program