Provider Demographics
NPI:1215358353
Name:JORDAN, TREMAINE
Entity Type:Individual
Prefix:
First Name:TREMAINE
Middle Name:
Last Name:JORDAN
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 1:2401 BUENA VISTA RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31906-3142
Mailing Address - Country:US
Mailing Address - Phone:706-323-7244
Mailing Address - Fax:706-596-0424
Practice Address - Street 1:2401 BUENA VISTA RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31906-3142
Practice Address - Country:US
Practice Address - Phone:706-323-7244
Practice Address - Fax:706-596-0424
Is Sole Proprietor?:No
Enumeration Date:2013-12-16
Last Update Date:2013-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA050982144172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker