MEDICARE: THEA JEAN JORDAN O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	02656T	TX

General Provider Information

NPI Number	:	1124335294
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	THEA JEAN JORDAN O.D.

Provider Business Mailing Address
First Line	:	13515 N STEMMONS FWY
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75234-5765
Country	:	US
Telephone Number	:	678-358-8826
Fax Number	:

Provider Business Practice Location Address
First Line	:	13515 N STEMMONS FWY
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75234-5765
Country	:	US
Telephone Number	:	678-358-8826
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/09/2010
Last Update Date	:	11/29/2011

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