MEDICARE: MARIE JORDA

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	163W00000X	Registered Nurse	144542	FL

General Provider Information

NPI Number	:	1871841601
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARIE JORDA

Provider Business Mailing Address
First Line	:	4404 SW SHADD ST
Second Line	:
City	:	PORT SAINT LUCIE
State	:	FL
Zip	:	34953-6093
Country	:	US
Telephone Number	:	772-201-2638
Fax Number	:

Provider Business Practice Location Address
First Line	:	5150 NW MILNER ROAD
Second Line	:
City	:	PORT SAINT LUCIE
State	:	FL
Zip	:	34983
Country	:	US
Telephone Number	:	772-201-2638
Fax Number	:

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

Provider Enumeration Date	:	08/28/2012
Last Update Date	:	08/28/2012

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