Provider Demographics
NPI:1396177069
Name:JORDAN, STACEY LYNN (LPO, CPO, BOC OP)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:LYNN
Last Name:JORDAN
Suffix:
Gender:M
Credentials:LPO, CPO, BOC OP
Other - Prefix:
Other - First Name:S.L.
Other - Middle Name:
Other - Last Name:JORDAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LPO, CPO, BOC OP
Mailing Address - Street 1:PO BOX 3702
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79116-3702
Mailing Address - Country:US
Mailing Address - Phone:806-353-7276
Mailing Address - Fax:806-353-7539
Practice Address - Street 1:441 S WESTERN ST
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79106-8555
Practice Address - Country:US
Practice Address - Phone:806-353-7276
Practice Address - Fax:806-353-7539
Is Sole Proprietor?:No
Enumeration Date:2013-08-05
Last Update Date:2013-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX488222Z00000X, 224P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
No224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist