Healthcare Provider Details

I. General information

NPI: 1952795106
Provider Name (Legal Business Name): JORDAN LICATA DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2015
Last Update Date: 12/12/2024
Certification Date: 12/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1821 N WASHINGTON ST
TULLAHOMA TN
37388-2221
US

IV. Provider business mailing address

1821 N WASHINGTON ST
TULLAHOMA TN
37388-2221
US

V. Phone/Fax

Practice location:
  • Phone: 931-461-5056
  • Fax: 931-455-4450
Mailing address:
  • Phone: 931-461-5056
  • Fax: 931-455-4450

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number05799
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number5294
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: