Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 111N00000X | Chiropractor | DC36021 | CA |
Y | 111NN1001X | Nutrition | DC36021 | CA |
N | 111NS0005X | Chiropractic Sports Physician | DC36021 | CA |
NPI | 1245822758 |
---|---|
Provider Name | Dr. Jordan Michael Maxwell |
First Address | San Diego, CA 92108-1232 |
Second Address | San Diego, CA 92108-1232 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 05/02/2021 |
Last Update Date | 05/02/2021 |