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General NPI Number Information
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NPI Number | 1750295945
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Entity Type | Individual
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Provider Name | IRADIS JORDAN
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Gender | Female
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Dates
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Enumeration Date | 10/02/2026
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Last Update Date | 10/02/2026
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Provider Practice Location Address
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Address Line | 1020 TITAN CT STE 102
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City | FORT WALTON BEACH
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State | FL
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Zip | 32547-6638
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Country | US
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Telephone | 850-863-7581
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Fax | 833-355-1090
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Provider Business Mailing Address
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Address Line | 107 MARLBERRY TRCE
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City | SANTA ROSA BEACH
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State | FL
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Zip | 32459-3375
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225200000X
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Taxonomy Name | Physical Therapy Assistant
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License Number |
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License Number State | NULL
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