Provider Demographics
NPI:1639651359
Name:JORDAN, MELISSA DAWN
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:DAWN
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 1:17722 FM 974
Mailing Address - Street 2:
Mailing Address - City:BRYAN
Mailing Address - State:TX
Mailing Address - Zip Code:77808-8780
Mailing Address - Country:US
Mailing Address - Phone:979-218-6531
Mailing Address - Fax:
Practice Address - Street 1:17722 FM 974
Practice Address - Street 2:
Practice Address - City:BRYAN
Practice Address - State:TX
Practice Address - Zip Code:77808-8780
Practice Address - Country:US
Practice Address - Phone:979-218-6531
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-29
Last Update Date:2018-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX344069164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
344069OtherTBON