MEDICARE: JORDAN CJ SU LIA

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	171100000X	Acupuncturist	002036	NY

General Provider Information

NPI Number	:	1427932052
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JORDAN CJ SU LIA

Provider Business Mailing Address
First Line	:	2 NORMANSKILL BLVD STE 204
Second Line	:
City	:	DELMAR
State	:	NY
Zip	:	12054-1331
Country	:	US
Telephone Number	:	518-364-5934
Fax Number	:

Provider Business Practice Location Address
First Line	:	2 NORMANSKILL BLVD STE 204
Second Line	:
City	:	DELMAR
State	:	NY
Zip	:	12054-1331
Country	:	US
Telephone Number	:	518-364-5934
Fax Number	:

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

Provider Enumeration Date	:	08/05/2025
Last Update Date	:	08/05/2025

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