Healthcare Provider Details

I. General information

NPI: 1568373363
Provider Name (Legal Business Name): KEUNNA MARIE JORDAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2026
Last Update Date: 09/14/2026
Certification Date: 09/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

820 PINE AVE SE
WARREN OH
44483-6524
US

IV. Provider business mailing address

1380 FRANCIS AVE SE
WARREN OH
44484-4941
US

V. Phone/Fax

Practice location:
  • Phone: 330-394-8831
  • Fax:
Mailing address:
  • Phone: 234-699-3219
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: