Healthcare Provider Details

I. General information

NPI: 1063644672
Provider Name (Legal Business Name): DOROTHY HENRY JORDAN R.N., PMHCNS-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/14/2009
Last Update Date: 10/21/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1920 BRAIRCLIFF ROAD NE MARCUS AUTISM CENTER
ATLANTA GA
30329-4010
US

IV. Provider business mailing address

2194 EDISON AVE NE
ATLANTA GA
30305-4309
US

V. Phone/Fax

Practice location:
  • Phone: 404-785-9420
  • Fax: 404-785-9410
Mailing address:
  • Phone: 404-963-6619
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN061785
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code364SP0808X
TaxonomyPsychiatric/Mental Health Clinical Nurse Specialist
License NumberRN061785
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: