Healthcare Provider Details

I. General information

NPI: 1851908016
Provider Name (Legal Business Name): TAKENYA LACOLE JORDAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/30/2020
Last Update Date: 12/27/2024
Certification Date: 12/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2231 DAWSON RD STE IJ
ALBANY GA
31707-3227
US

IV. Provider business mailing address

2231 DAWSON RD STE IJ
ALBANY GA
31707-3227
US

V. Phone/Fax

Practice location:
  • Phone: 229-938-2083
  • Fax: 888-780-7250
Mailing address:
  • Phone: 229-938-2083
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: