Provider Demographics
NPI:1881920221
Name:JORDAHL, JE'NE NYCOLE (DC)
Entity type:Individual
Prefix:DR
First Name:JE'NE
Middle Name:NYCOLE
Last Name:JORDAHL
Suffix:
Gender:F
Credentials:DC
Other - Prefix:DR
Other - First Name:JE'NE
Other - Middle Name:NYCOLE
Other - Last Name:RANDALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DC
Mailing Address - Street 1:933 MILL ROAD LN
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32127-4865
Mailing Address - Country:US
Mailing Address - Phone:386-299-3434
Mailing Address - Fax:
Practice Address - Street 1:4705 S CLYDE MORRIS BLVD
Practice Address - Street 2:
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32129-4103
Practice Address - Country:US
Practice Address - Phone:386-763-2718
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-20
Last Update Date:2013-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH9827111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL006099400Medicaid