Provider Demographics
NPI:1518316058
Name:JORDAN ANSTEAD, MARY (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:
Last Name:JORDAN ANSTEAD
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 338
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:FL
Mailing Address - Zip Code:33576-0338
Mailing Address - Country:US
Mailing Address - Phone:813-618-0157
Mailing Address - Fax:
Practice Address - Street 1:32007 HARTMAN RD
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:FL
Practice Address - Zip Code:33576-8175
Practice Address - Country:US
Practice Address - Phone:813-618-0157
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-06
Last Update Date:2016-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL$$$$$$$$$Medicaid