Healthcare Provider Details

I. General information

NPI: 1326304775
Provider Name (Legal Business Name): FAREESA NICOLE JORDAN O.P.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2012
Last Update Date: 04/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9180 KATY FWY SUITE 202
HOUSTON TX
77055-7454
US

IV. Provider business mailing address

9180 KATY FWY SUITE 202
HOUSTON TX
77055-7454
US

V. Phone/Fax

Practice location:
  • Phone: 713-647-7700
  • Fax: 713-647-7702
Mailing address:
  • Phone: 713-647-7700
  • Fax: 713-647-7702

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZS0410X
TaxonomySurgical Technologist
License Number902
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: