Provider Demographics
NPI:1457972945
Name:JORDAN, PHYLLIS LIZETTA (MHP)
Entity Type:Individual
Prefix:MS
First Name:PHYLLIS
Middle Name:LIZETTA
Last Name:JORDAN
Suffix:
Gender:F
Credentials:MHP
Other - Prefix:
Other - First Name:PHYLLIS
Other - Middle Name:
Other - Last Name:JORDAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MA/MS
Mailing Address - Street 1:721 FAWCETT AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98402-5502
Mailing Address - Country:US
Mailing Address - Phone:253-207-4312
Mailing Address - Fax:253-207-4318
Practice Address - Street 1:721 FAWCETT AVE STE 101721S
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98402-5502
Practice Address - Country:US
Practice Address - Phone:253-207-4312
Practice Address - Fax:253-207-4318
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-06
Last Update Date:2020-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAJORDAPL361NUOtherDRIVER'S LICENSE