Healthcare Provider Details

I. General information

NPI: 1447607999
Provider Name (Legal Business Name): VERNON JORDAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/14/2016
Last Update Date: 05/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

74 WESTMINISTER DR
LITTLE ROCK AR
72209-2949
US

IV. Provider business mailing address

PO BOX 13624
MAUMELLE AR
72113-0624
US

V. Phone/Fax

Practice location:
  • Phone: 501-414-8224
  • Fax:
Mailing address:
  • Phone: 501-414-8224
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code172A00000X
TaxonomyDriver
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State
# 9
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 10
Primary TaxonomyN
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License Number
License Number State
# 11
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State
# 12
Primary TaxonomyN
Taxonomy Code3747A0650X
TaxonomyAttendant Care Provider
License Number
License Number State
# 13
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: