Provider Demographics
NPI:1790569374
Name:JORDAN VANN, MICHAEL A
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:A
Last Name:JORDAN VANN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:JAMES
Other - Middle Name:HAROLD
Other - Last Name:VANN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MIHAEL JORDAN VANN
Mailing Address - Street 1:1618 CLIMBING DAYFLOWER DR
Mailing Address - Street 2:
Mailing Address - City:RUSKIN
Mailing Address - State:FL
Mailing Address - Zip Code:33570-4949
Mailing Address - Country:US
Mailing Address - Phone:813-461-9502
Mailing Address - Fax:
Practice Address - Street 1:1618 CLIMBING DAYFLOWER DR
Practice Address - Street 2:
Practice Address - City:RUSKIN
Practice Address - State:FL
Practice Address - Zip Code:33570-4949
Practice Address - Country:US
Practice Address - Phone:813-461-9502
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-23
Last Update Date:2023-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator