1861610313 NPI number — MS. MOREEN JORDAN

Table of content: MS. MOREEN JORDAN (NPI 1861610313)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861610313 NPI number — MS. MOREEN JORDAN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JORDAN
Provider First Name:
MOREEN
Provider Middle Name:
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1861610313
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/02/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 31603
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TUCSON
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85751-1603
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
520-869-7052
Provider Business Mailing Address Fax Number:
520-303-9205

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7301 E 22ND ST
Provider Second Line Business Practice Location Address:
SUITE 10-E
Provider Business Practice Location Address City Name:
TUCSON
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85710-6426
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
520-869-7052
Provider Business Practice Location Address Fax Number:
520-303-2905
Provider Enumeration Date:
04/22/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  LPC-10407 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 106H00000X , with the licence number: LPC-10407 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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