Provider Demographics
NPI:1316502024
Name:JORDAN, CLIFTON ANTHONY (MASTER BARBER)
Entity type:Individual
Prefix:MR
First Name:CLIFTON
Middle Name:ANTHONY
Last Name:JORDAN
Suffix:
Gender:M
Credentials:MASTER BARBER
Other - Prefix:MR
Other - First Name:CLIFTON
Other - Middle Name:ANTHONY
Other - Last Name:JORDAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MASTER BARBER
Mailing Address - Street 1:215 W 27TH AVE
Mailing Address - Street 2:
Mailing Address - City:CORDELE
Mailing Address - State:GA
Mailing Address - Zip Code:31015-3854
Mailing Address - Country:US
Mailing Address - Phone:229-406-0499
Mailing Address - Fax:
Practice Address - Street 1:1106 EAST AVE SUITE J
Practice Address - Street 2:
Practice Address - City:CORDELE
Practice Address - State:GA
Practice Address - Zip Code:31015
Practice Address - Country:US
Practice Address - Phone:229-406-0499
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-08
Last Update Date:2020-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1744P3200X
GABR019994335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management
No335E00000XSuppliersProsthetic/Orthotic Supplier