Provider Demographics
NPI:1538746284
Name:HATCH, JORDAN (MD)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:HATCH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5215 HOLY CROSS PKWY
Mailing Address - Street 2:PROVIDER SERVICES-ENROLLMENT
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46545-1469
Mailing Address - Country:US
Mailing Address - Phone:574-335-8707
Mailing Address - Fax:
Practice Address - Street 1:2930 W CLEVELAND ROAD EXT
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46628-6090
Practice Address - Country:US
Practice Address - Phone:574-335-8450
Practice Address - Fax:574-335-0780
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-27
Last Update Date:2024-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IN01092640A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300050952Medicaid