Basic Information
| Provider Information | |||||||||
| NPI: | 1720657802 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JORDAN | ||||||||
| FirstName: | SHON | ||||||||
| MiddleName: | D'ANN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 285 LASA COMMONS CIR APT 111 | ||||||||
| Address2: | |||||||||
| City: | SAINT AUGUSTINE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320848795 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6154950174 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1838 GREENE TREE RD STE 245 | ||||||||
| Address2: | |||||||||
| City: | PIKESVILLE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212087110 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4105495700 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2021 | ||||||||
| LastUpdateDate: | 06/22/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.