Provider Demographics
NPI:1770931859
Name:JORDAN, SAMUEL
Entity type:Individual
Prefix:
First Name:SAMUEL
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 1:1541 S POINT RD
Mailing Address - Street 2:
Mailing Address - City:BELMONT
Mailing Address - State:NC
Mailing Address - Zip Code:28012-8544
Mailing Address - Country:US
Mailing Address - Phone:704-713-4328
Mailing Address - Fax:
Practice Address - Street 1:1541 S POINT RD
Practice Address - Street 2:
Practice Address - City:BELMONT
Practice Address - State:NC
Practice Address - Zip Code:28012-8544
Practice Address - Country:US
Practice Address - Phone:704-713-4328
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-30
Last Update Date:2016-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker