MEDICARE: TIFFANY JORDAN CERTIFIED HAIR LOSS

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	224P00000X	Prosthetist

General Provider Information

NPI Number	:	1417539883
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TIFFANY JORDAN CERTIFIED HAIR LOSS

Provider Business Mailing Address
First Line	:	2358 GRASMERE AVE
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43211-2058
Country	:	US
Telephone Number	:	614-680-6057
Fax Number	:

Provider Business Practice Location Address
First Line	:	2525 FRANKSWAY ST
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43232-4204
Country	:	US
Telephone Number	:	614-680-6057
Fax Number	:

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

Provider Enumeration Date	:	04/26/2021
Last Update Date	:	04/26/2021

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