Provider Demographics
NPI:1124335294
Name:JORDAN, THEA JEAN (OD)
Entity type:Individual
Prefix:
First Name:THEA
Middle Name:JEAN
Last Name:JORDAN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:THEA
Other - Middle Name:JEAN
Other - Last Name:JORDAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:13515 N STEMMONS FWY
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75234-5765
Mailing Address - Country:US
Mailing Address - Phone:678-358-8826
Mailing Address - Fax:
Practice Address - Street 1:13515 N STEMMONS FWY
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75234-5765
Practice Address - Country:US
Practice Address - Phone:678-358-8826
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-09
Last Update Date:2011-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX02656T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist