Provider Demographics
NPI:1851948178
Name:JORDAN, KORTNEY
Entity Type:Individual
Prefix:
First Name:KORTNEY
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 1:323 SE 24TH AVE APT A
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33990-1419
Mailing Address - Country:US
Mailing Address - Phone:239-745-0206
Mailing Address - Fax:
Practice Address - Street 1:3900 COLONIAL BLVD STE 1
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33966-1014
Practice Address - Country:US
Practice Address - Phone:239-351-3715
Practice Address - Fax:239-771-8732
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-21
Last Update Date:2019-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician