Provider Demographics
NPI:1639413727
Name:JORDAN, ELIZABETH (MED)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:JORDAN
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1425 E 28TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11210-5312
Mailing Address - Country:US
Mailing Address - Phone:718-258-2525
Mailing Address - Fax:
Practice Address - Street 1:1425 E 28TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11210-5312
Practice Address - Country:US
Practice Address - Phone:718-258-2525
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-15
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY746935174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist