Basic Information
| Provider Information | |||||||||
| NPI: | 1588158794 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JORDAN | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | |||||||||
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| Credential: | BCABA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 175 MIDDLE ST UNIT 1201 | ||||||||
| Address2: | |||||||||
| City: | LAKE MARY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327463625 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8666100580 | ||||||||
| FaxNumber: | 4075886294 | ||||||||
| Practice Location | |||||||||
| Address1: | 6976 PROFESSIONAL PKWY E | ||||||||
| Address2: | |||||||||
| City: | LAKEWOOD RANCH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 34240 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9413084641 | ||||||||
| FaxNumber: | 9413426189 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2018 | ||||||||
| LastUpdateDate: | 09/06/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106E00000X | 0-18-8907 | N | 106E00000X | Y |
No ID Information.