Provider Demographics
NPI:1831970235
Name:ANDERSON, JORDEAN
Entity type:Individual
Prefix:
First Name:JORDEAN
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2440 WISTERIA DR
Mailing Address - Street 2:
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30078-0337
Mailing Address - Country:US
Mailing Address - Phone:216-306-7838
Mailing Address - Fax:
Practice Address - Street 1:2440 WISTERIA DR UNIT 1643
Practice Address - Street 2:
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30078-4842
Practice Address - Country:US
Practice Address - Phone:404-801-4101
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-11
Last Update Date:2025-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA071217669172A00000X, 342000000X
376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes342000000XTransportation ServicesTransportation Network Company
No172A00000XOther Service ProvidersDriver
No376K00000XNursing Service Related ProvidersNurse's Aide