MEDICARE: SHONDA 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	164W00000X	Licensed Practical Nurse	PN1298901	FL

General Provider Information

NPI Number	:	1689858060
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHONDA JORDAN

Provider Business Mailing Address
First Line	:	1004 INDIAN TRACE CIR
Second Line	:	APT 203
City	:	WEST PALM BEACH
State	:	FL
Zip	:	33407-1146
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1004 INDIAN TRACE CIR
Second Line	:	APT 203
City	:	WEST PALM BEACH
State	:	FL
Zip	:	33407-1146
Country	:	US
Telephone Number	:	561-840-6808
Fax Number	:

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

Provider Enumeration Date	:	12/21/2007
Last Update Date	:	12/21/2007

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