Provider Demographics
NPI:1659669265
Name:JORDAN, MARIA TERESA (MA ECSE)
Entity Type:Individual
Prefix:MRS
First Name:MARIA
Middle Name:TERESA
Last Name:JORDAN
Suffix:
Gender:F
Credentials:MA ECSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3337 N KOLMAR AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60641-4546
Mailing Address - Country:US
Mailing Address - Phone:773-960-5156
Mailing Address - Fax:
Practice Address - Street 1:3337 N KOLMAR AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60641-4546
Practice Address - Country:US
Practice Address - Phone:773-960-5156
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-16
Last Update Date:2011-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2393772222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist