Healthcare Provider Details

I. General information

NPI: 1679802292
Provider Name (Legal Business Name): YMEIKA JORDAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/10/2009
Last Update Date: 12/10/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1485 INTERNATIONAL PKWY
HEATHROW FL
32746-5303
US

IV. Provider business mailing address

1485 INTERNATIONAL PKWY
HEATHROW FL
32746-5303
US

V. Phone/Fax

Practice location:
  • Phone: 800-798-6035
  • Fax: 888-798-6035
Mailing address:
  • Phone: 800-798-6035
  • Fax: 888-798-6035

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number0131000661
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: