| Doctor Name: | DR. JORDAN WILLIAM WILDE |
| NPI Number: | 1922370543 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | D.C. |
| License Number: | 5033 |
| Business Practice Address: | 191 Se Stark Street Gresham, OR - 972338386 |
| Business Phone Number: | 5033289300 |
| Business Fax Number: | |
| Mailing Address: | 1040 Sw 66th Ave Apt 7210, PORTLAND |
| State: | OR |
| Postal Code: | 972256082 |
| Phone Number: | |
| Fax Number: | |
| NPI Enumeration Date: | 01/27/2012 |
| NPI Last Update Date: | 03/14/2013 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 111N00000X |
| License Number: | 5033 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | OR |
| Taxonomy Type: | Chiropractic Providers |
| Taxonomy Classification: | Chiropractor |
| Taxonomy Specialization: | |
| Taxonomy Definition: | A provider qualified by a Doctor of Chiropractic (D.C.), licensed by the State and who practices chiropractic medicine -that discipline within the healing arts which deals with the nervous system and its relationship to the spinal column and its interrelationship with other body systems. |