Provider Demographics
NPI:1649035197
Name:JORDAN, TAYLOR
Entity type:Individual
Prefix:
First Name:TAYLOR
Middle Name:
Last Name:JORDAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3605 SCHOOLHOUSE RD W UNIT 410
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33916-8191
Mailing Address - Country:US
Mailing Address - Phone:813-309-6702
Mailing Address - Fax:
Practice Address - Street 1:3605 SCHOOLHOUSE RD W UNIT 410
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33916-8191
Practice Address - Country:US
Practice Address - Phone:813-309-6702
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-14
Last Update Date:2024-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9511630163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty