Provider Demographics
NPI:1902197007
Name:MERRILL, JORDAN W (MD)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:W
Last Name:MERRILL
Suffix:
Gender:M
Credentials:MD
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Other - First Name:
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Mailing Address - Street 1:1032 S. BRIDGEWAY PL.
Mailing Address - Street 2:STE 110
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616
Mailing Address - Country:US
Mailing Address - Phone:208-475-0800
Mailing Address - Fax:208-639-0901
Practice Address - Street 1:1032 S. BRIDGEWAY PL.
Practice Address - Street 2:STE 110
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616
Practice Address - Country:US
Practice Address - Phone:208-475-0800
Practice Address - Fax:208-639-0901
Is Sole Proprietor?:No
Enumeration Date:2011-04-22
Last Update Date:2021-11-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IDM-130012084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry