Provider Demographics
NPI:1134673643
Name:COFFELT, JORDAN ALYSE (AUD)
Entity Type:Individual
Prefix:DR
First Name:JORDAN ALYSE
Middle Name:
Last Name:COFFELT
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4055 N PARK LOOP
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38152-4220
Mailing Address - Country:US
Mailing Address - Phone:901-678-2009
Mailing Address - Fax:901-678-5497
Practice Address - Street 1:4055 N PARK LOOP
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38152-4220
Practice Address - Country:US
Practice Address - Phone:901-678-2009
Practice Address - Fax:901-678-5497
Is Sole Proprietor?:No
Enumeration Date:2016-08-12
Last Update Date:2020-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR426231H00000X
MSA4402231H00000X
TN1761231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ059461Medicaid