Provider Demographics
NPI:1740661867
Name:JORDAN, LARISSA MICHELLE (MA)
Entity type:Individual
Prefix:
First Name:LARISSA
Middle Name:MICHELLE
Last Name:JORDAN
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 HAWKINS DR
Mailing Address - Street 2:
Mailing Address - City:IOWA CITY
Mailing Address - State:IA
Mailing Address - Zip Code:52242-1025
Mailing Address - Country:US
Mailing Address - Phone:319-335-8736
Mailing Address - Fax:319-335-8851
Practice Address - Street 1:250 HAWKINS DR
Practice Address - Street 2:
Practice Address - City:IOWA CITY
Practice Address - State:IA
Practice Address - Zip Code:52242-1025
Practice Address - Country:US
Practice Address - Phone:319-335-8736
Practice Address - Fax:319-335-8851
Is Sole Proprietor?:No
Enumeration Date:2015-06-15
Last Update Date:2015-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA075305235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist