Healthcare Provider Details

I. General information

NPI: 1851857478
Provider Name (Legal Business Name): JORDAN JAMAL JONES
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/19/2019
Last Update Date: 02/06/2020
Certification Date: 02/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 BEVILLE RD STE 403
DAYTONA BEACH FL
32114
US

IV. Provider business mailing address

1500 BEVILLE RD STE 403
DAYTONA BEACH FL
32114-5644
US

V. Phone/Fax

Practice location:
  • Phone: 386-253-6634
  • Fax:
Mailing address:
  • Phone: 386-253-6634
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDN24607
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: