Provider Demographics
NPI:1790545051
Name:JORDAN IBRAHIM COMMUNITY SERVICES
Entity Type:Organization
Organization Name:JORDAN IBRAHIM COMMUNITY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-482-1708
Mailing Address - Street 1:200 E BESSEMER AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27401-1416
Mailing Address - Country:US
Mailing Address - Phone:336-482-1708
Mailing Address - Fax:
Practice Address - Street 1:200 E BESSEMER AVE STE 100
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27401-1416
Practice Address - Country:US
Practice Address - Phone:336-482-1708
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-21
Last Update Date:2024-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness