Provider Demographics
NPI:1740093244
Name:JORDAN, DESIREE
Entity type:Individual
Prefix:
First Name:DESIREE
Middle Name:
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 1:3900 NORTHSIDE DR, MACON, GA 31210, USA
Mailing Address - Street 2:D15
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31210
Mailing Address - Country:US
Mailing Address - Phone:478-219-0968
Mailing Address - Fax:
Practice Address - Street 1:3872 PIO NONO AVE
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31206-3042
Practice Address - Country:US
Practice Address - Phone:478-219-0968
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-29
Last Update Date:2025-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACOA010392332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies