Provider Demographics
NPI:1588263107
Name:JORDAN, MARQUETTA (STNA)
Entity type:Individual
Prefix:
First Name:MARQUETTA
Middle Name:
Last Name:JORDAN
Suffix:
Gender:F
Credentials:STNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1112 SILVER MEADOWS BLVD
Mailing Address - Street 2:
Mailing Address - City:KENT
Mailing Address - State:OH
Mailing Address - Zip Code:44240-1850
Mailing Address - Country:US
Mailing Address - Phone:330-541-3245
Mailing Address - Fax:
Practice Address - Street 1:1112 SILVER MEADOWS BLVD
Practice Address - Street 2:
Practice Address - City:KENT
Practice Address - State:OH
Practice Address - Zip Code:44240-1850
Practice Address - Country:US
Practice Address - Phone:330-541-3245
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-23
Last Update Date:2020-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH402221941119376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide