Provider Demographics
NPI:1013660125
Name:JORDAN, DESTYNIE
Entity Type:Individual
Prefix:
First Name:DESTYNIE
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 1:2205 OUSLEYDALE RD
Mailing Address - Street 2:
Mailing Address - City:HARTSVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29550-8733
Mailing Address - Country:US
Mailing Address - Phone:843-260-9062
Mailing Address - Fax:
Practice Address - Street 1:2205 OUSLEYDALE RD
Practice Address - Street 2:
Practice Address - City:HARTSVILLE
Practice Address - State:SC
Practice Address - Zip Code:29550-8733
Practice Address - Country:US
Practice Address - Phone:843-260-9062
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-28
Last Update Date:2022-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date: