Provider Demographics
NPI:1871972059
Name:JORDAN, REGINA R
Entity type:Individual
Prefix:MRS
First Name:REGINA
Middle Name:R
Last Name:JORDAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:REGINA
Other - Middle Name:R
Other - Last Name:JORDAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3341 W NORTH AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53208-1457
Mailing Address - Country:US
Mailing Address - Phone:414-837-0008
Mailing Address - Fax:
Practice Address - Street 1:3341 W NORTH AVE STE 101
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53208-1457
Practice Address - Country:US
Practice Address - Phone:414-837-0008
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-21
Last Update Date:2015-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator