Provider Demographics
NPI:1831477595
Name:JORDAN, TINA MARIE (LMT)
Entity Type:Individual
Prefix:MRS
First Name:TINA
Middle Name:MARIE
Last Name:JORDAN
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
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Mailing Address - Street 1:4640 LIPSCOMB ST NE
Mailing Address - Street 2:SUITE 16
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32905-2986
Mailing Address - Country:US
Mailing Address - Phone:321-723-2340
Mailing Address - Fax:321-723-3137
Practice Address - Street 1:4640 LIPSCOMB ST NE
Practice Address - Street 2:SUITE 16
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32905-2986
Practice Address - Country:US
Practice Address - Phone:321-723-2340
Practice Address - Fax:321-723-3137
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-29
Last Update Date:2011-07-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLMM16481225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist