Provider Demographics
NPI:1952795106
Name:LICATA, JORDAN (DO)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:LICATA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1821 N WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:TULLAHOMA
Mailing Address - State:TN
Mailing Address - Zip Code:37388-2221
Mailing Address - Country:US
Mailing Address - Phone:931-461-5056
Mailing Address - Fax:931-455-4450
Practice Address - Street 1:1821 N WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:TULLAHOMA
Practice Address - State:TN
Practice Address - Zip Code:37388-2221
Practice Address - Country:US
Practice Address - Phone:931-461-5056
Practice Address - Fax:931-455-4450
Is Sole Proprietor?:No
Enumeration Date:2015-03-26
Last Update Date:2024-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY05799207Y00000X
TN5294207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology