Provider Demographics
NPI:1174197594
Name:EADES, ALEXANDER JORDAN
Entity Type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:JORDAN
Last Name:EADES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 N MARIE DR
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32401-4053
Mailing Address - Country:US
Mailing Address - Phone:850-851-7716
Mailing Address - Fax:
Practice Address - Street 1:850 N TYNDALL PKWY
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32404-9407
Practice Address - Country:US
Practice Address - Phone:850-866-0441
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-19
Last Update Date:2021-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL21151406106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician