Healthcare Provider Details

I. General information

NPI: 1902006034
Provider Name (Legal Business Name): JAUDONNA P JORDAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2007
Last Update Date: 07/18/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1087 ALICE AVE
MEMPHIS TN
38106-6543
US

IV. Provider business mailing address

1303 GLENN ST
MEMPHIS TN
38106-4321
US

V. Phone/Fax

Practice location:
  • Phone: 901-259-1920
  • Fax: 901-259-1922
Mailing address:
  • Phone: 901-259-1920
  • Fax: 901-259-1922

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: