Provider Demographics
NPI:1104979731
Name:JORDAN, TAMMARA ANN (MS,CCC-SLP)
Entity type:Individual
Prefix:
First Name:TAMMARA
Middle Name:ANN
Last Name:JORDAN
Suffix:
Gender:F
Credentials:MS,CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 S 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-7246
Mailing Address - Country:US
Mailing Address - Phone:601-579-3310
Mailing Address - Fax:601-579-5240
Practice Address - Street 1:102 MEDICAL PARK
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39401
Practice Address - Country:US
Practice Address - Phone:601-261-5159
Practice Address - Fax:601-545-1740
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2020-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSS2203235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS7346349OtherAETNA
MS0800517OtherCIGNA
MS1772892Medicaid
MS731632210OtherMS CHIP
MS6061226OtherHEALTHSPRINGS
MS3504919OtherUNITED HEALTHCARE
MS731632210OtherUNITED HEALTH CARE
MS7345349OtherAETNA
MS731632210OtherUNITED HEALTH CARE