Provider Demographics
NPI:1073560652
Name:JORDAN, LESA (MD)
Entity Type:Individual
Prefix:
First Name:LESA
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 1:710 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38107-2310
Mailing Address - Country:US
Mailing Address - Phone:901-626-2266
Mailing Address - Fax:
Practice Address - Street 1:710 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38107-2310
Practice Address - Country:US
Practice Address - Phone:901-626-2266
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-28
Last Update Date:2014-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN35942207P00000X
MS18383207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3880023Medicaid
P00427604OtherRAILROAD MCR
MS04939709Medicaid
TN3880023Medicaid
P00427604OtherRAILROAD MCR
TN3880023Medicare UPIN
MS04939709Medicaid
TN38800211Medicare PIN