MEDICARE: SHANEL MARIE JORDAN

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	174400000X	Specialist

General Provider Information

NPI Number	:	1598231524
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANEL MARIE JORDAN

Provider Business Mailing Address
First Line	:	4827 N 76TH ST
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53218-3826
Country	:	US
Telephone Number	:	414-324-1207
Fax Number	:

Provider Business Practice Location Address
First Line	:	4827 N 76TH ST
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53218-3826
Country	:	US
Telephone Number	:	414-324-1207
Fax Number	:

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

Provider Enumeration Date	:	10/17/2018
Last Update Date	:	10/17/2018

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Directions to “ SHANEL MARIE JORDAN ” Practice Location

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