MEDICARE: MRS. SHANTAE MARIE JONES JORDAN RN

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	163W00000X	Registered Nurse	RN.396756	OH

General Provider Information

NPI Number	:	1790116812
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. SHANTAE MARIE JONES JORDAN RN

Provider Business Mailing Address
First Line	:	1291 E 186TH ST
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44110-2862
Country	:	US
Telephone Number	:	216-326-0021
Fax Number	:

Provider Business Practice Location Address
First Line	:	1291 E 186TH ST
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44110-2862
Country	:	US
Telephone Number	:	216-326-0021
Fax Number	:

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

Provider Enumeration Date	:	11/30/2013
Last Update Date	:	11/30/2013

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