Provider Demographics
NPI:1235970625
Name:JORDAN, ALIZA
Entity type:Individual
Prefix:
First Name:ALIZA
Middle Name:
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 1:2515 ALLEN RD
Mailing Address - Street 2:
Mailing Address - City:SMITHDALE
Mailing Address - State:MS
Mailing Address - Zip Code:39664-4081
Mailing Address - Country:US
Mailing Address - Phone:601-384-6501
Mailing Address - Fax:
Practice Address - Street 1:PO BOX 1848
Practice Address - Street 2:
Practice Address - City:UNIVERSITY
Practice Address - State:MS
Practice Address - Zip Code:38677-1848
Practice Address - Country:US
Practice Address - Phone:662-915-7901
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-01
Last Update Date:2024-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer