Provider Demographics
NPI:1730766213
Name:BREEDING, JORDAN NICOLE
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:NICOLE
Last Name:BREEDING
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 1:2603 DELOR AVE
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40217-2301
Mailing Address - Country:US
Mailing Address - Phone:812-599-7412
Mailing Address - Fax:
Practice Address - Street 1:10000 BROWNSBORO RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40241-3900
Practice Address - Country:US
Practice Address - Phone:502-890-7760
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-29
Last Update Date:2022-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY106191223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1730766213Medicaid