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General NPI Number Information
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NPI Number | 1437423878
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Entity Type | Organization
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Legal Business Name | CARMEN S JORDAN
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Dates
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Enumeration Date | 03/02/2012
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Last Update Date | 03/02/2012
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Provider Practice Location Address
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Address Line | 1102 18TH ST
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City | ROCKFORD
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State | IL
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Zip | 61104-3422
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Country | US
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Telephone | 815-978-5181
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Fax |
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Provider Business Mailing Address
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Address Line | 1102 18TH ST
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City | ROCKFORD
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State | IL
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Zip | 61104-3422
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Country | US
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Telephone | 815-978-5181
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MS. CARMEN S JORDAN
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Credential | CCC-SLP
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Telephone | 815-978-5181
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 252Y00000X
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Taxonomy Name | Early Intervention Provider Agency
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License Number | CJ05640701P
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 235Z00000X
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Taxonomy Name | Speech-Language Pathologist
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License Number | 146.007060
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License Number State | IL
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