Basic Information
| Provider Information | |||||||||
| NPI: | 1902078066 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMALLWOOD | ||||||||
| FirstName: | JORDAN | ||||||||
| MiddleName: | CHRISTOPHER | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | DEPT. 453 PO BOX 1000 | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381480001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8285752625 | ||||||||
| FaxNumber: | 8283502174 | ||||||||
| Practice Location | |||||||||
| Address1: | 14 MCDOWELL ST | ||||||||
| Address2: | |||||||||
| City: | ASHEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 288014104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8282553749 | ||||||||
| FaxNumber: | 8282549925 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/28/2008 | ||||||||
| LastUpdateDate: | 09/22/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/22/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207K00000X | ME 116755 | FL | Y | Allopathic & Osteopathic Physicians | Allergy & Immunology | 207K00000X | 2022-02522 | NC | N | Allopathic & Osteopathic Physicians | Allergy & Immunology |
ID Information
| ID | Type | State | Issuer | Description | 1902078066 | 05 | NC | MEDICAID | NNN346A | 01 | NC | MEDICARE PTAN | OTHER |