Healthcare Provider Details

I. General information

NPI: 1861964165
Provider Name (Legal Business Name): THERESA A JORDAN DBA TRENT'S TEAM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/26/2018
Last Update Date: 06/01/2020
Certification Date: 06/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3812 E PIKES PEAK AVE STE 205
COLORADO SPRINGS CO
80909-6781
US

IV. Provider business mailing address

3812 E PIKES PEAK AVE STE 205
COLORADO SPRINGS CO
80909-6781
US

V. Phone/Fax

Practice location:
  • Phone: 719-660-5663
  • Fax: 719-434-9603
Mailing address:
  • Phone: 719-660-5663
  • Fax: 719-434-9603

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code376J00000X
TaxonomyHomemaker
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code385HR2060X
TaxonomyChild Intellectual and/or Developmental Disabilities Respite Care
License Number
License Number StateNULL
# 5
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: