Provider Demographics
NPI:1063292019
Name:JORDAN, KAITLYN
Entity type:Individual
Prefix:
First Name:KAITLYN
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 1:2075 NEW YORK AVE
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11746-3238
Mailing Address - Country:US
Mailing Address - Phone:631-351-7112
Mailing Address - Fax:
Practice Address - Street 1:2075 NEW YORK AVE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON STATION
Practice Address - State:NY
Practice Address - Zip Code:11746-3238
Practice Address - Country:US
Practice Address - Phone:631-351-7112
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-05
Last Update Date:2023-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program