Provider Demographics
NPI:1043739113
Name:JORDAN-DEAN, KAVONDA SHERICA (MED)
Entity Type:Individual
Prefix:MRS
First Name:KAVONDA
Middle Name:SHERICA
Last Name:JORDAN-DEAN
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 197
Mailing Address - Street 2:
Mailing Address - City:FARMVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:23901
Mailing Address - Country:US
Mailing Address - Phone:434-395-4973
Mailing Address - Fax:434-395-2969
Practice Address - Street 1:315 WEST THIRD STREET
Practice Address - Street 2:
Practice Address - City:FARMVILLE
Practice Address - State:VA
Practice Address - Zip Code:23901
Practice Address - Country:US
Practice Address - Phone:434-395-4973
Practice Address - Fax:434-395-2969
Is Sole Proprietor?:No
Enumeration Date:2017-09-11
Last Update Date:2017-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator