Provider Demographics
NPI:1497831424
Name:JORDAN, SALLY C (MD)
Entity Type:Individual
Prefix:DR
First Name:SALLY
Middle Name:C
Last Name:JORDAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:955 YONKERS AVENUE
Mailing Address - Street 2:BOX 21
Mailing Address - City:YONKERS
Mailing Address - State:NY
Mailing Address - Zip Code:10704
Mailing Address - Country:US
Mailing Address - Phone:914-472-5140
Mailing Address - Fax:914-472-5270
Practice Address - Street 1:955 YONKERS AVE STE 100
Practice Address - Street 2:
Practice Address - City:YONKERS
Practice Address - State:NY
Practice Address - Zip Code:10704-3062
Practice Address - Country:US
Practice Address - Phone:914-472-5140
Practice Address - Fax:914-473-5270
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-31
Last Update Date:2018-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY154001-1174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1540011OtherLICENSE
NY1540011OtherLICENSE