Healthcare Provider Details

I. General information

NPI: 1457815664
Provider Name (Legal Business Name): JORDAN LEA GOAD NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/22/2019
Last Update Date: 04/26/2021
Certification Date: 04/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1483 TOBIAS GADSON BLVD STE 107
CHARLESTON SC
29407-4795
US

IV. Provider business mailing address

1065 NE 125TH ST STE 300
NORTH MIAMI FL
33161-5833
US

V. Phone/Fax

Practice location:
  • Phone: 843-745-5153
  • Fax: 843-766-8606
Mailing address:
  • Phone: 888-852-6672
  • Fax: 305-891-4228

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberRN282704
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPN.21159
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: