Provider Demographics
NPI:1225546153
Name:JORDAN, TYSHONNA DOMRAE
Entity Type:Individual
Prefix:
First Name:TYSHONNA
Middle Name:DOMRAE
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 1:5310 MOODY DR
Mailing Address - Street 2:
Mailing Address - City:NORTH DINWIDDIE
Mailing Address - State:VA
Mailing Address - Zip Code:23803-8706
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12318 BOYDTON PLANK RD.
Practice Address - Street 2:
Practice Address - City:DINWIDDIE
Practice Address - State:VA
Practice Address - Zip Code:23841
Practice Address - Country:US
Practice Address - Phone:804-504-9089
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-12
Last Update Date:2021-04-12
Deactivation Date:2018-01-30
Deactivation Code:
Reactivation Date:2021-04-12
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health