Provider Demographics
NPI:1740972363
Name:JORDAN, MICHELLE (LDO)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:JORDAN
Suffix:
Gender:F
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1505 COUNTY ROAD 220
Mailing Address - Street 2:
Mailing Address - City:FLEMING ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32003-7926
Mailing Address - Country:US
Mailing Address - Phone:904-215-4945
Mailing Address - Fax:904-264-2871
Practice Address - Street 1:1505 COUNTY ROAD 220
Practice Address - Street 2:
Practice Address - City:FLEMING ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32003-7926
Practice Address - Country:US
Practice Address - Phone:904-215-4945
Practice Address - Fax:904-264-2871
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-23
Last Update Date:2023-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDO5615156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician