Healthcare Provider Details

I. General information

NPI: 1275779423
Provider Name (Legal Business Name): TIFFANY NICHOL JORDAN PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/17/2008
Last Update Date: 10/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2120 S MCCLINTOCK DR STE 105
TEMPE AZ
85282-2692
US

IV. Provider business mailing address

1400 E SOUTHERN AVE STE 735
TEMPE AZ
85282-5691
US

V. Phone/Fax

Practice location:
  • Phone: 480-804-0326
  • Fax:
Mailing address:
  • Phone: 480-804-0326
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAP3218
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: