Provider Demographics
NPI:1033653258
Name:JORDAL, MELISSA SUE (LMT)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:SUE
Last Name:JORDAL
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26121 US ROUTE 11
Mailing Address - Street 2:
Mailing Address - City:EVANS MILLS
Mailing Address - State:NY
Mailing Address - Zip Code:13637-3318
Mailing Address - Country:US
Mailing Address - Phone:315-778-9221
Mailing Address - Fax:
Practice Address - Street 1:26121 US ROUTE 11
Practice Address - Street 2:
Practice Address - City:EVANS MILLS
Practice Address - State:NY
Practice Address - Zip Code:13637-3318
Practice Address - Country:US
Practice Address - Phone:315-778-9221
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-06
Last Update Date:2016-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY025879-1225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist