Provider Demographics
NPI:1841934379
Name:JORDAN, LESLIE RENEE
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:RENEE
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 1:5349 STRAIGHT FRK
Mailing Address - Street 2:
Mailing Address - City:GRIFFITHSVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:25521-9509
Mailing Address - Country:US
Mailing Address - Phone:304-237-2807
Mailing Address - Fax:
Practice Address - Street 1:5349 STRAIGHT FRK
Practice Address - Street 2:
Practice Address - City:GRIFFITHSVILLE
Practice Address - State:WV
Practice Address - Zip Code:25521-9509
Practice Address - Country:US
Practice Address - Phone:304-237-2807
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-21
Last Update Date:2022-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant