Provider Demographics
NPI:1871910398
Name:JORDAN, SHERYL (PTA)
Entity type:Individual
Prefix:
First Name:SHERYL
Middle Name:
Last Name:JORDAN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34222 BERRYFROST LN
Mailing Address - Street 2:
Mailing Address - City:POTEAU
Mailing Address - State:OK
Mailing Address - Zip Code:74953-9002
Mailing Address - Country:US
Mailing Address - Phone:918-208-1119
Mailing Address - Fax:
Practice Address - Street 1:34222 BERRYFROST LN
Practice Address - Street 2:
Practice Address - City:POTEAU
Practice Address - State:OK
Practice Address - Zip Code:74953-9002
Practice Address - Country:US
Practice Address - Phone:918-208-1119
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-21
Last Update Date:2014-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1969314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility