Provider Demographics
NPI:1558679936
Name:JORDAN, SANDRA S (MED)
Entity type:Individual
Prefix:MS
First Name:SANDRA
Middle Name:S
Last Name:JORDAN
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2213
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH CITY
Mailing Address - State:NC
Mailing Address - Zip Code:27906-2213
Mailing Address - Country:US
Mailing Address - Phone:252-339-6842
Mailing Address - Fax:252-330-2001
Practice Address - Street 1:106 PAILIN CREEK RD
Practice Address - Street 2:
Practice Address - City:ELIZABETH CITY
Practice Address - State:NC
Practice Address - Zip Code:27909-2924
Practice Address - Country:US
Practice Address - Phone:252-339-6842
Practice Address - Fax:252-330-2001
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-19
Last Update Date:2010-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No251B00000XAgenciesCase Management