Provider Demographics
NPI:1972304186
Name:JORDAN, KANISHA
Entity type:Individual
Prefix:
First Name:KANISHA
Middle Name:
Last Name:JORDAN
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2201 E 46TH ST STE 119
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46205-1449
Mailing Address - Country:US
Mailing Address - Phone:317-289-9077
Mailing Address - Fax:317-289-9077
Practice Address - Street 1:2201 E 46TH ST STE 119
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46205-1449
Practice Address - Country:US
Practice Address - Phone:317-289-9077
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-24
Last Update Date:2025-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN300104002172V00000X, 253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes253Z00000XAgenciesIn Home Supportive Care
No172V00000XOther Service ProvidersCommunity Health WorkerGroup - Multi-Specialty