Provider Demographics
NPI:1417347220
Name:DATTOLI, JORDAN
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:DATTOLI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:424 SAVANNAH RD
Mailing Address - Street 2:
Mailing Address - City:LEWES
Mailing Address - State:DE
Mailing Address - Zip Code:19958-1462
Mailing Address - Country:US
Mailing Address - Phone:302-645-3554
Mailing Address - Fax:
Practice Address - Street 1:424 SAVANNAH RD
Practice Address - Street 2:
Practice Address - City:LEWES
Practice Address - State:DE
Practice Address - Zip Code:19958-1462
Practice Address - Country:US
Practice Address - Phone:302-645-3554
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-31
Last Update Date:2015-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEL1-0042013163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse