Basic Information
| Provider Information | |||||||||
| NPI: | 1477214559 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JORDAN | ||||||||
| FirstName: | MIKIAVIDILIA | ||||||||
| MiddleName: | SHARELLE YVONNE | ||||||||
| NamePrefix: | MISS | ||||||||
| NameSuffix: | |||||||||
| Credential: | N/A | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | JORDAN | ||||||||
| OtherFirstName: | KIA | ||||||||
| OtherMiddleName: | SY | ||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | N/A | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 18726 S WESTERN AVE | ||||||||
| Address2: | |||||||||
| City: | GARDENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902483813 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3108560800 | ||||||||
| FaxNumber: | 8555682494 | ||||||||
| Practice Location | |||||||||
| Address1: | 5400 W PLANO PKWY STE 200 | ||||||||
| Address2: | |||||||||
| City: | PLANO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750934855 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8889222843 | ||||||||
| FaxNumber: | 8555682494 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/31/2021 | ||||||||
| LastUpdateDate: | 12/31/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/31/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | Y |
No ID Information.