Basic Information
| Provider Information | |||||||||
| NPI: | 1366614505 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JORDAN | ||||||||
| FirstName: | THERESA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | MS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6035 FAIRVIEW RD | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282103256 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7042953300 | ||||||||
| FaxNumber: | 7042953468 | ||||||||
| Practice Location | |||||||||
| Address1: | 6035 FAIRVIEW RD | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282103256 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7042953300 | ||||||||
| FaxNumber: | 7042953468 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/27/2008 | ||||||||
| LastUpdateDate: | 03/16/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 237600000X | 667 | NC | N | Speech, Language and Hearing Service Providers | Audiologist-Hearing Aid Fitter | 231H00000X | 2218 | NC | Y | Speech, Language and Hearing Service Providers | Audiologist |
ID Information
| ID | Type | State | Issuer | Description | 30109414 | 01 | SC | SELECT HEALTH | OTHER | SAN010 | 05 | SC | MEDICAID | 9890230 | 01 | AENTA | OTHER | 6335254 | 01 | CIGNA | OTHER | 16271 | 01 | NC | BCBSNC | OTHER | 7413304 | 05 | NC | MEDICAID | P01044553 | 01 | NC | RAILROAD MEDICARE PTAN | OTHER | 879963 | 01 | SC | WELLCARE OF SC | OTHER |