Provider Demographics
NPI:1447733712
Name:JORDAN, WALTER JEROME
Entity Type:Individual
Prefix:MR
First Name:WALTER
Middle Name:JEROME
Last Name:JORDAN
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 1:600 40TH ST N APT 111
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33713-6339
Mailing Address - Country:US
Mailing Address - Phone:727-657-8392
Mailing Address - Fax:
Practice Address - Street 1:600 40TH ST N APT 111
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33713-6339
Practice Address - Country:US
Practice Address - Phone:727-657-8392
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-12
Last Update Date:2018-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL235565251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL235565OtherAGENCY FOR HEALTH CARE ADMINISTRATION