Healthcare Provider Details

I. General information

NPI: 1245404136
Provider Name (Legal Business Name): JOSEPH JORDAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/22/2008
Last Update Date: 04/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

206 HOLLYWOOD CT N
KISSIMMEE FL
34743-7846
US

IV. Provider business mailing address

206 HOLLYWOOD CT N
KISSIMMEE FL
34743-7846
US

V. Phone/Fax

Practice location:
  • Phone: 407-348-5030
  • Fax: 407-348-5030
Mailing address:
  • Phone: 407-348-5030
  • Fax: 407-348-5030

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253J00000X
TaxonomyFoster Care Agency
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: