Provider Demographics
NPI:1225386949
Name:JORDAN, PEARLINE P
Entity Type:Individual
Prefix:MS
First Name:PEARLINE
Middle Name:P
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 1:780 CONCOURSE VLG W
Mailing Address - Street 2:APT 19B
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10451-3805
Mailing Address - Country:US
Mailing Address - Phone:718-538-3288
Mailing Address - Fax:
Practice Address - Street 1:780 CONCOURSE VLG W
Practice Address - Street 2:APT 19B
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10451-3805
Practice Address - Country:US
Practice Address - Phone:718-538-3288
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-28
Last Update Date:2012-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
133N00000X
NY46161133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist