Provider Demographics
NPI:1326304775
Name:JORDAN, FAREESA NICOLE (OPA)
Entity Type:Individual
Prefix:MS
First Name:FAREESA
Middle Name:NICOLE
Last Name:JORDAN
Suffix:
Gender:F
Credentials:OPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9180 KATY FWY
Mailing Address - Street 2:SUITE 202
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77055-7454
Mailing Address - Country:US
Mailing Address - Phone:713-647-7700
Mailing Address - Fax:713-647-7702
Practice Address - Street 1:9180 KATY FWY
Practice Address - Street 2:SUITE 202
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77055-7454
Practice Address - Country:US
Practice Address - Phone:713-647-7700
Practice Address - Fax:713-647-7702
Is Sole Proprietor?:No
Enumeration Date:2012-04-10
Last Update Date:2012-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
902246ZS0410X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist