Provider Demographics
NPI:1700266608
Name:JORDAN, STACY ANN (DO)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:ANN
Last Name:JORDAN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3152 LITTLE RD # 162
Mailing Address - Street 2:
Mailing Address - City:TRINITY
Mailing Address - State:FL
Mailing Address - Zip Code:34655-1864
Mailing Address - Country:US
Mailing Address - Phone:847-289-5727
Mailing Address - Fax:847-888-5469
Practice Address - Street 1:2025 INDIAN ROCKS RD S
Practice Address - Street 2:
Practice Address - City:LARGO
Practice Address - State:FL
Practice Address - Zip Code:33774-1035
Practice Address - Country:US
Practice Address - Phone:847-289-9572
Practice Address - Fax:847-888-5469
Is Sole Proprietor?:No
Enumeration Date:2015-06-05
Last Update Date:2021-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101021920208100000X, 208D00000X
FLOS16125208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice