Provider Demographics
NPI:1114218039
Name:JORDAN, MESSALINA CHARISSE (DO)
Entity Type:Individual
Prefix:
First Name:MESSALINA
Middle Name:CHARISSE
Last Name:JORDAN
Suffix:
Gender:F
Credentials:DO
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 22
Mailing Address - Street 2:
Mailing Address - City:BOAZ
Mailing Address - State:AL
Mailing Address - Zip Code:35957-0022
Mailing Address - Country:US
Mailing Address - Phone:256-849-0500
Mailing Address - Fax:256-573-1021
Practice Address - Street 1:3520 US HIGHWAY 431 STE 100
Practice Address - Street 2:
Practice Address - City:ALBERTVILLE
Practice Address - State:AL
Practice Address - Zip Code:35950-0082
Practice Address - Country:US
Practice Address - Phone:256-849-0500
Practice Address - Fax:256-573-1021
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-26
Last Update Date:2020-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALDO1305207Q00000X
KS05-38426207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALDO1305OtherALBME