Provider Demographics
NPI:1801211933
Name:JORDAN, MELBA
Entity Type:Individual
Prefix:MS
First Name:MELBA
Middle Name:
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 1:10825 72ND AVE
Mailing Address - Street 2:APT: 2K
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-5368
Mailing Address - Country:US
Mailing Address - Phone:646-243-7933
Mailing Address - Fax:
Practice Address - Street 1:10825 72ND AVE
Practice Address - Street 2:APT 2K
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-5368
Practice Address - Country:US
Practice Address - Phone:646-243-7933
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-26
Last Update Date:2014-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY22-494697163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool