Individual
JORDAN GROVE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
1100 WILFORD HALL LOOP, JBSA LACKLAND, TX 78236-5638
(210) 916-4789
Mailing address
1100 WILFORD HALL LOOP, JBSA LACKLAND, TX 78236-5638
(210) 916-4789
Taxonomy
Speciality
Code
Description
License number
State
207P00000X
Emergency Medicine Physician
Primary
U5706
TX
208D00000X
General Practice Physician
0101273843
VA
390200000X
Student in an Organized Health Care Education/Training Program
—
—
Other
Enumeration date
04/24/2020
Last updated
08/17/2023
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