Provider Demographics
NPI:1497545073
Name:JORDAN, IESHA ANN
Entity type:Individual
Prefix:MISS
First Name:IESHA
Middle Name:ANN
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 1:3608 E POWHATAN AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33610-3725
Mailing Address - Country:US
Mailing Address - Phone:813-485-2015
Mailing Address - Fax:
Practice Address - Street 1:1329 EMERALD HILL WAY
Practice Address - Street 2:
Practice Address - City:VALRICO
Practice Address - State:FL
Practice Address - Zip Code:33594-5027
Practice Address - Country:US
Practice Address - Phone:813-485-2015
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-08
Last Update Date:2025-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities