Provider Demographics
NPI:1386380541
Name:JORDAN, LAKISHA LATOYA
Entity type:Individual
Prefix:
First Name:LAKISHA
Middle Name:LATOYA
Last Name:JORDAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LAKISHA
Other - Middle Name:L
Other - Last Name:HARROLD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:9 CHESAPEAKE PLZ
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:OH
Mailing Address - Zip Code:45619-1003
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:220 S BREIEL BLVD STE 4
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:OH
Practice Address - Zip Code:45044-5106
Practice Address - Country:US
Practice Address - Phone:513-849-8670
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-10
Last Update Date:2023-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH171M00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator