Provider Demographics
NPI:1962863316
Name:JORDAN, SHATAWN NIYKEL (STNA)
Entity type:Individual
Prefix:
First Name:SHATAWN
Middle Name:NIYKEL
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 1:3619 ESQUIRE DR
Mailing Address - Street 2:
Mailing Address - City:CANAL WINCHESTER
Mailing Address - State:OH
Mailing Address - Zip Code:43110-9421
Mailing Address - Country:US
Mailing Address - Phone:614-900-0086
Mailing Address - Fax:
Practice Address - Street 1:3619 ESQUIRE DR
Practice Address - Street 2:
Practice Address - City:CANAL WINCHESTER
Practice Address - State:OH
Practice Address - Zip Code:43110-9421
Practice Address - Country:US
Practice Address - Phone:614-900-0086
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-14
Last Update Date:2016-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH401451821012376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide