Provider Demographics
NPI:1962986869
Name:JORDAN, ROBERTA ELLEN
Entity type:Individual
Prefix:
First Name:ROBERTA
Middle Name:ELLEN
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:MAPLEWOOD MAYFLOWER PLACE SNF, LLC
Mailing Address - Street 2:579 BUCK ISLAND ROAD
Mailing Address - City:WEST YARMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02673
Mailing Address - Country:US
Mailing Address - Phone:508-957-7007
Mailing Address - Fax:508-790-8116
Practice Address - Street 1:579 BUCK ISLAND RD
Practice Address - Street 2:
Practice Address - City:WEST YARMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02673-3200
Practice Address - Country:US
Practice Address - Phone:508-957-7007
Practice Address - Fax:508-790-8116
Is Sole Proprietor?:No
Enumeration Date:2018-09-18
Last Update Date:2018-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1183001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical