Kenneth N Jordan, DO

Primary specialty

Family Medicine PhysicianTaxonomy code 207Q00000X

License

003036052185 Issued in IL

Practice address

520 West Madison Street
Madison Street Clinic PC
Pontiac, IL 61764

Phone

(815) 844-6106

Fax

(815) 842-2526

NPI assigned

Sep 11, 2006

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other identifiers 1

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Osteopathy

State licenses

Practice roles

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Madison Street Clinic P.C.

  • Family Medicine Physician
  • Pontiac, IL
  • NPI 1518189786
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1157932800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1183852800000",
    "number": "1710081708",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "520 WEST MADISON",
            "city": "PONTIAC",
            "state": "IL",
            "postal_code": "61764",
            "telephone_number": "815-844-6106",
            "fax_number": "815-842-2526"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "520 WEST MADISON STREET",
            "address_2": "MADISON STREET CLINIC PC",
            "city": "PONTIAC",
            "state": "IL",
            "postal_code": "61764",
            "telephone_number": "815-844-6106",
            "fax_number": "815-842-2526"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "JORDAN",
        "first_name": "KENNETH",
        "middle_name": "N",
        "credential": "DO",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2006-09-11",
        "last_updated": "2007-07-08",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "IL",
            "license": "003036052185",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "036052185",
            "state": "IL"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• J C Purnell MD SC
• Nicole M. Jack, PA-C
• Heather Ann Taylor Jackson, APRN, WHNP-BC
• John W. Rinker
• Andrew D Jordan, DDS
• Arianne M Kaack, PHARMD
• Katie Kennedy
• Misty Kessinger, BS
• Kimberly K Kidner, D.C.
• Laurel Kietzman, MD

• Family Medicine Physician in Pontiac, IL
• Providers in Pontiac, IL by specialty
• Family Medicine Physician in Illinois

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 8, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.