Provider Demographics
NPI:1730794322
Name:JORDAN, KASSIDI LEIGH
Entity type:Individual
Prefix:
First Name:KASSIDI
Middle Name:LEIGH
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 1:5080 SCARSDALE DR
Mailing Address - Street 2:
Mailing Address - City:KETTERING
Mailing Address - State:OH
Mailing Address - Zip Code:45440-2421
Mailing Address - Country:US
Mailing Address - Phone:937-701-3904
Mailing Address - Fax:
Practice Address - Street 1:6601 AUTUMN GLEN DR
Practice Address - Street 2:
Practice Address - City:WEST CHESTER
Practice Address - State:OH
Practice Address - Zip Code:45069-1479
Practice Address - Country:US
Practice Address - Phone:937-701-3904
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-10
Last Update Date:2020-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide