Healthcare Provider Details

I. General information

NPI: 1386573251
Provider Name (Legal Business Name): MS. CARLLISA ROSHEA JORDAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/18/2026
Last Update Date: 05/18/2026
Certification Date: 05/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5234 RED HILL DR
INDIAN HEAD MD
20640-3401
US

IV. Provider business mailing address

5234 RED HILL DR
INDIAN HEAD MD
20640-3401
US

V. Phone/Fax

Practice location:
  • Phone: 301-752-5852
  • Fax:
Mailing address:
  • Phone: 301-752-5852
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: