Healthcare Provider Details

I. General information

NPI: 1902783848
Provider Name (Legal Business Name): JORDAN KEZIAH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/20/2025
Last Update Date: 08/20/2025
Certification Date: 08/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2830 E BROWN RD STE 1
MESA AZ
85213-5431
US

IV. Provider business mailing address

1497 E PINTO CT
GILBERT AZ
85296-3120
US

V. Phone/Fax

Practice location:
  • Phone: 602-875-5608
  • Fax:
Mailing address:
  • Phone: 480-416-0915
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License NumberSLPA15195
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: