Healthcare Provider Details

I. General information

NPI: 1366990830
Provider Name (Legal Business Name): JORDANIA PSYCHIATRY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2016
Last Update Date: 09/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25111 PENNYROYAL DR
BONITA SPRINGS FL
34134
US

IV. Provider business mailing address

25111 PENNYROYAL DR
BONITA SPRINGS FL
34134
US

V. Phone/Fax

Practice location:
  • Phone: 630-740-8375
  • Fax:
Mailing address:
  • Phone: 630-740-8375
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License NumberME126750
License Number StateFL

VIII. Authorized Official

Name: DR. NINA JORDANIA
Title or Position: ONWER/PHYSICIAN
Credential: MD
Phone: 630-740-8375