Provider Demographics
NPI:1558912725
Name:TATE, JORDON TAYLOR
Entity Type:Individual
Prefix:
First Name:JORDON
Middle Name:TAYLOR
Last Name:TATE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1620 SQUIRE HART WAY
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40515-5395
Mailing Address - Country:US
Mailing Address - Phone:859-358-4926
Mailing Address - Fax:
Practice Address - Street 1:2375 PROFESSIONAL HEIGHTS DR STE 240
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40503-3040
Practice Address - Country:US
Practice Address - Phone:855-591-0092
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-27
Last Update Date:2019-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator