Provider Demographics
NPI:1407967508
Name:JORDAN, CORETTA (CNA)
Entity Type:Individual
Prefix:
First Name:CORETTA
Middle Name:
Last Name:JORDAN
Suffix:
Gender:F
Credentials:CNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 351
Mailing Address - Street 2:
Mailing Address - City:MCGEHEE
Mailing Address - State:AR
Mailing Address - Zip Code:71654-0351
Mailing Address - Country:US
Mailing Address - Phone:870-222-3806
Mailing Address - Fax:870-222-3984
Practice Address - Street 1:901 S 3RD ST
Practice Address - Street 2:
Practice Address - City:MCGEHEE
Practice Address - State:AR
Practice Address - Zip Code:71654-2563
Practice Address - Country:US
Practice Address - Phone:870-222-3806
Practice Address - Fax:870-222-3984
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR058628920598E374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide