Provider Demographics
NPI:1962090886
Name:JORDAN, NAKIA STACI
Entity type:Individual
Prefix:
First Name:NAKIA
Middle Name:STACI
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 1:5 GWYNNS MILL CT STE A
Mailing Address - Street 2:
Mailing Address - City:OWINGS MILLS
Mailing Address - State:MD
Mailing Address - Zip Code:21117-3529
Mailing Address - Country:US
Mailing Address - Phone:443-414-1607
Mailing Address - Fax:
Practice Address - Street 1:5 GWYNNS MILL CT STE A
Practice Address - Street 2:
Practice Address - City:OWINGS MILLS
Practice Address - State:MD
Practice Address - Zip Code:21117-3529
Practice Address - Country:US
Practice Address - Phone:443-414-1607
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-06
Last Update Date:2023-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251E00000X
MD0163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD1457940389Medicaid