Basic Information
| Provider Information | |||||||||
| NPI: | 1487155644 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JORDAN | ||||||||
| FirstName: | ALYSA | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1600 ROBERTA DR SW APT 2306 | ||||||||
| Address2: | |||||||||
| City: | MARIETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300083883 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3472167560 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 923 DILL AVE SW STE A | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303104145 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4047533141 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/23/2018 | ||||||||
| LastUpdateDate: | 02/23/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 111N00000X | CHIR010015 | GA | Y | Chiropractic Providers | Chiropractor |
No ID Information.