Provider Demographics
NPI:1124766084
Name:JORDAN, TAMMISHA (MASSAGE THERAPIST)
Entity type:Individual
Prefix:
First Name:TAMMISHA
Middle Name:
Last Name:JORDAN
Suffix:
Gender:F
Credentials:MASSAGE THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1716 N LINDER AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60639-4220
Mailing Address - Country:US
Mailing Address - Phone:312-774-1144
Mailing Address - Fax:
Practice Address - Street 1:1716 N LINDER AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60639-4220
Practice Address - Country:US
Practice Address - Phone:312-774-1144
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-21
Last Update Date:2022-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227022538225700000X
225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty