Provider Demographics
NPI:1336974724
Name:JORDAN, BASHEBA JAZEL
Entity type:Individual
Prefix:
First Name:BASHEBA
Middle Name:JAZEL
Last Name:JORDAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5755 BONNERTON RD
Mailing Address - Street 2:
Mailing Address - City:EDWARD
Mailing Address - State:NC
Mailing Address - Zip Code:27821-9712
Mailing Address - Country:US
Mailing Address - Phone:252-497-6621
Mailing Address - Fax:
Practice Address - Street 1:905 FRIEDBERG CHURCH RD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27127-9803
Practice Address - Country:US
Practice Address - Phone:336-251-1160
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-04
Last Update Date:2024-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician