Provider Demographics
NPI:1437423878
Name:CARMEN S JORDAN
Entity Type:Organization
Organization Name:CARMEN S JORDAN
Other - Org Name:CORE SPEECH PATHOLOGY SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:CARMEN
Authorized Official - Middle Name:S
Authorized Official - Last Name:JORDAN
Authorized Official - Suffix:
Authorized Official - Credentials:CCC-SLP
Authorized Official - Phone:815-978-5181
Mailing Address - Street 1:1102 18TH ST
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61104-3422
Mailing Address - Country:US
Mailing Address - Phone:815-978-5181
Mailing Address - Fax:
Practice Address - Street 1:1102 18TH ST
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61104-3422
Practice Address - Country:US
Practice Address - Phone:815-978-5181
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-02
Last Update Date:2012-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146.007060235Z00000X
ILCJ05640701P252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
No252Y00000XAgenciesEarly Intervention Provider AgencyGroup - Single Specialty