Provider Demographics
NPI:1053976068
Name:JORDAN, ANISSA
Entity type:Individual
Prefix:
First Name:ANISSA
Middle Name:
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 1:4024 MAGUIRE BLVD APT 1310
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32803-7215
Mailing Address - Country:US
Mailing Address - Phone:305-570-6169
Mailing Address - Fax:
Practice Address - Street 1:6900 TAVISTOCK LAKES BLVD STE 400
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32827-7593
Practice Address - Country:US
Practice Address - Phone:407-970-0824
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-06
Last Update Date:2019-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSZ8935235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist