Provider Demographics
NPI:1093931198
Name:JORDAN, TAMAJAH MARIE (MD)
Entity Type:Individual
Prefix:DR
First Name:TAMAJAH
Middle Name:MARIE
Last Name:JORDAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:TAMAJAH
Other - Middle Name:MARIE
Other - Last Name:GIBSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3231 EUCLID AVE FL 5
Mailing Address - Street 2:
Mailing Address - City:BERWYN
Mailing Address - State:IL
Mailing Address - Zip Code:60402-4603
Mailing Address - Country:US
Mailing Address - Phone:708-783-2000
Mailing Address - Fax:
Practice Address - Street 1:3231 EUCLID AVE FL 5
Practice Address - Street 2:
Practice Address - City:BERWYN
Practice Address - State:IL
Practice Address - Zip Code:60402-4603
Practice Address - Country:US
Practice Address - Phone:708-783-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-17
Last Update Date:2022-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA96062208D00000X
IL036118836207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA96062OtherMEDICAL BOARD LICENSE
IL036118836OtherMEDICAL LICENSE