Healthcare Provider Details

I. General information

NPI: 1588125470
Provider Name (Legal Business Name): ATASHA A JORDAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/25/2019
Last Update Date: 07/17/2023
Certification Date: 07/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 COOPER PLZ RM 307
CAMDEN NJ
08103-1438
US

IV. Provider business mailing address

1 FEDERAL ST # 200
CAMDEN NJ
08103-1088
US

V. Phone/Fax

Practice location:
  • Phone: 856-342-2328
  • Fax: 856-541-6137
Mailing address:
  • Phone: 848-288-6935
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number25MA11846000
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: