Provider Demographics
NPI:1437446432
Name:JORDAN, TARA LEIGH (OD)
Entity Type:Individual
Prefix:DR
First Name:TARA
Middle Name:LEIGH
Last Name:JORDAN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:LEIGH
Other - Last Name:ENGSTROM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:3303A GLYNN AVE
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:GA
Mailing Address - Zip Code:31520-4406
Mailing Address - Country:US
Mailing Address - Phone:912-466-9500
Mailing Address - Fax:912-466-9922
Practice Address - Street 1:3303A GLYNN AVE
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:GA
Practice Address - Zip Code:31520-4406
Practice Address - Country:US
Practice Address - Phone:912-466-9500
Practice Address - Fax:912-466-9922
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-29
Last Update Date:2023-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT002683152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAOPT002683OtherGA LICENSE
GAOPT002683OtherGA LICENSE
SC1652OtherSC LICENSE NUMBER 1652
SCAA7466F935Medicare PIN