Provider Demographics
NPI:1245380252
Name:FAINE-SIADMAN, JORDANA B (MSPT)
Entity Type:Individual
Prefix:
First Name:JORDANA
Middle Name:B
Last Name:FAINE-SIADMAN
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3601 NE 25 AVENUE
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33308
Mailing Address - Country:US
Mailing Address - Phone:954-568-0682
Mailing Address - Fax:
Practice Address - Street 1:3601 NE 25TH AVE
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33308-6301
Practice Address - Country:US
Practice Address - Phone:954-568-0682
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-11
Last Update Date:2014-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT19480225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL886456000Medicaid
FL886456000Medicaid