Provider Demographics
NPI:1104126085
Name:TILMAN, JORDYN E (MA)
Entity type:Individual
Prefix:
First Name:JORDYN
Middle Name:E
Last Name:TILMAN
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 WESTWOOD TER N
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33710-8325
Mailing Address - Country:US
Mailing Address - Phone:727-347-9096
Mailing Address - Fax:
Practice Address - Street 1:45 WESTWOOD TER N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33710-8325
Practice Address - Country:US
Practice Address - Phone:727-347-9096
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-26
Last Update Date:2012-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH8945101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL029556600Medicaid