Healthcare Provider Details

I. General information

NPI: 1750295945
Provider Name (Legal Business Name): IRADIS JORDAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2026
Last Update Date: 10/02/2026
Certification Date: 10/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1020 TITAN CT STE 102
FORT WALTON BEACH FL
32547-6638
US

IV. Provider business mailing address

107 MARLBERRY TRCE
SANTA ROSA BEACH FL
32459-3375
US

V. Phone/Fax

Practice location:
  • Phone: 850-863-7581
  • Fax: 833-355-1090
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: