Provider Demographics
NPI:1114397130
Name:JORDAN, RENEE R
Entity Type:Individual
Prefix:
First Name:RENEE
Middle Name:R
Last Name:JORDAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2281 OSHKOSH CT
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32818-5258
Mailing Address - Country:US
Mailing Address - Phone:407-451-0245
Mailing Address - Fax:
Practice Address - Street 1:2281 OSHKOSH CT
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32818-5258
Practice Address - Country:US
Practice Address - Phone:407-451-0245
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-02
Last Update Date:2020-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL251C00000X
251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No251C00000XAgenciesDay Training, Developmentally Disabled Services