=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285069757
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JORDAN MANAGEMENT GROUP, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/03/2013
-----------------------------------------------------
Last Update Date | 09/03/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 905 HALSTEAD BLVD STE 5
-----------------------------------------------------
City | ELIZABETH CITY
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27909-6986
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 252-334-1560
-----------------------------------------------------
Fax | 252-334-1563
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 2213
-----------------------------------------------------
City | ELIZABETH CITY
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27906-2213
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 252-334-1560
-----------------------------------------------------
Fax | 252-334-1563
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SOLE MEMBER/CHIEF EXECUTIVE OFFICER
-----------------------------------------------------
Name | MS. SANDRA S. JORDAN
-----------------------------------------------------
Credential | M.ED.
-----------------------------------------------------
Telephone | 252-334-1560
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251J00000X
-----------------------------------------------------
Taxonomy Name | Nursing Care Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 253Z00000X
-----------------------------------------------------
Taxonomy Name | In Home Supportive Care Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 332U00000X
-----------------------------------------------------
Taxonomy Name | Home Delivered Meals
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 333300000X
-----------------------------------------------------
Taxonomy Name | Emergency Response System Companies
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #6
-----------------------------------------------------
Taxonomy Code | 385H00000X
-----------------------------------------------------
Taxonomy Name | Respite Care
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #7
-----------------------------------------------------
Taxonomy Code | 251B00000X
-----------------------------------------------------
Taxonomy Name | Case Management Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------