Provider Demographics
NPI:1568510139
Name:JORDAN, PEGGY (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:PEGGY
Middle Name:
Last Name:JORDAN
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10307 ORCHARD HILLS CT
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33615-2577
Mailing Address - Country:US
Mailing Address - Phone:813-746-0387
Mailing Address - Fax:813-237-8593
Practice Address - Street 1:2401 E HENRY AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33610-4434
Practice Address - Country:US
Practice Address - Phone:813-988-7633
Practice Address - Fax:813-237-8593
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA8360235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist