MEDICARE: ALEXANDER JORDAN EADES

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	106S00000X	Behavior Technician	21151406	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1174197594
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALEXANDER JORDAN EADES

Provider Business Mailing Address
First Line	:	110 N MARIE DR
Second Line	:
City	:	PANAMA CITY
State	:	FL
Zip	:	32401-4053
Country	:	US
Telephone Number	:	850-851-7716
Fax Number	:

Provider Business Practice Location Address
First Line	:	850 N TYNDALL PKWY
Second Line	:
City	:	PANAMA CITY
State	:	FL
Zip	:	32404-9407
Country	:	US
Telephone Number	:	850-866-0441
Fax Number	:

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

Provider Enumeration Date	:	05/19/2021
Last Update Date	:	05/19/2021

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