Basic Information
| Provider Information | |||||||||
| NPI: | 1265013437 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LONGABAUGH | ||||||||
| FirstName: | JORDAN | ||||||||
| MiddleName: | JEAN | ||||||||
| NamePrefix: | MISS | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1010 N KANSAS ST | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672143124 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3162932665 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1010 N KANSAS ST | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672143124 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3162932665 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/19/2021 | ||||||||
| LastUpdateDate: | 07/14/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 03/27/2022 | ||||||||
| NPIReactivationDate: | 06/24/2022 | ||||||||
| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/14/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207V00000X | 94-10994 | KS | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
No ID Information.