Healthcare Provider Details

I. General information

NPI: 1639595309
Provider Name (Legal Business Name): LENISE MARLENA JORDAN NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/05/2014
Last Update Date: 05/03/2024
Certification Date: 04/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6085 OLD NATIONAL HWY STE G
SOUTH FULTON GA
30349-4333
US

IV. Provider business mailing address

6085 OLD NATIONAL HWY STE G
SOUTH FULTON GA
30349-4333
US

V. Phone/Fax

Practice location:
  • Phone: 844-644-4325
  • Fax: 855-583-3678
Mailing address:
  • Phone: 844-644-4325
  • Fax: 855-583-3678

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN162420
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: