Healthcare Provider Details

I. General information

NPI: 1558679936
Provider Name (Legal Business Name): SANDRA S JORDAN M.ED.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/19/2010
Last Update Date: 09/19/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 PAILIN CREEK RD
ELIZABETH CITY NC
27909-2924
US

IV. Provider business mailing address

PO BOX 2213
ELIZABETH CITY NC
27906-2213
US

V. Phone/Fax

Practice location:
  • Phone: 252-339-6842
  • Fax: 252-330-2001
Mailing address:
  • Phone: 252-339-6842
  • Fax: 252-330-2001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: