Provider Demographics
NPI:1568055051
Name:JORDAN, NANCY SUE
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:SUE
Last Name:JORDAN
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 1:1315 STARLIGHT CIR
Mailing Address - Street 2:
Mailing Address - City:EUSTIS
Mailing Address - State:FL
Mailing Address - Zip Code:32726-7544
Mailing Address - Country:US
Mailing Address - Phone:352-551-5773
Mailing Address - Fax:
Practice Address - Street 1:1621 BANNING BEACH RD
Practice Address - Street 2:
Practice Address - City:TAVARES
Practice Address - State:FL
Practice Address - Zip Code:32778-2054
Practice Address - Country:US
Practice Address - Phone:352-551-5773
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-16
Last Update Date:2021-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA52187225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist