Individual
JORDAN BLAKE FERGUSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
DO
Taxonomy
Speciality
Code
Description
License number
State
208000000X
Pediatrics Physician
Primary
02007657A
IN
208000000X
Pediatrics Physician
34.014921
OH
208000000X
Pediatrics Physician
DO-05346
IA
208000000X
Pediatrics Physician
R-10953
IA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1101473792
ANTHEM PTAN
IN
05
—
300090157
—
IN
Enumeration date
06/02/2017
Last updated
03/07/2025
Update your record
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