MEDICARE: KAWANDA JORDAN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	374U00000X	Home Health Aide

General Provider Information

NPI Number	:	1033628318
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KAWANDA JORDAN

Provider Business Mailing Address
First Line	:	7600 PACIFIC PL APT 1014
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76112-3717
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	7600 PACIFIC PL APT 1014
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76112-3717
Country	:	US
Telephone Number	:	601-573-9270
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/29/2017
Last Update Date	:	09/29/2017

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Directions to “ KAWANDA JORDAN ” Practice Location

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