Basic Information
| Provider Information | |||||||||
| NPI: | 1700266608 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JORDAN | ||||||||
| FirstName: | STACY | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3152 LITTLE RD # 162 | ||||||||
| Address2: | |||||||||
| City: | TRINITY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 346551864 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8472895727 | ||||||||
| FaxNumber: | 8478885469 | ||||||||
| Practice Location | |||||||||
| Address1: | 2025 INDIAN ROCKS RD S | ||||||||
| Address2: | |||||||||
| City: | LARGO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337741035 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8472899572 | ||||||||
| FaxNumber: | 8478885469 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/05/2015 | ||||||||
| LastUpdateDate: | 04/22/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | 5101021920 | MI | N | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | 208D00000X | 5101021920 | MI | N | Allopathic & Osteopathic Physicians | General Practice | 208100000X | OS16125 | FL | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
No ID Information.