Provider Demographics
NPI:1033140249
Name:JORDAN, SHANA (MD)
Entity Type:Individual
Prefix:
First Name:SHANA
Middle Name:
Last Name:JORDAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 W CARSON ST
Mailing Address - Street 2:N-25; #471
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90502-2004
Mailing Address - Country:US
Mailing Address - Phone:310-222-3382
Mailing Address - Fax:310-222-2882
Practice Address - Street 1:1333 CHESTNUT AVE
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90813-2944
Practice Address - Country:US
Practice Address - Phone:562-599-8601
Practice Address - Fax:562-218-0853
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA076315207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA076315OtherLICENSE NUMBER