MEDICARE: MICHELL M JORDAN DNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363L00000X	Nurse Practitioner	R197956	MD

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	97602401	OTHER	BCBS MD
2	0009541449	OTHER	AETNA PPO
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	8355618	OTHER	AETNA HMO
5	68320014	OTHER	BCBD FEDERAL

General Provider Information

NPI Number	:	1366524365
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHELL M JORDAN DNP

Provider Business Mailing Address
First Line	:	410 LOCKERMAN ST
Second Line	:
City	:	DENTON
State	:	MD
Zip	:	21629-1048
Country	:	US
Telephone Number	:	410-479-3075
Fax Number	:	833-914-0407

Provider Business Practice Location Address
First Line	:	410 LOCKERMAN ST
Second Line	:
City	:	DENTON
State	:	MD
Zip	:	21629-1048
Country	:	US
Telephone Number	:	410-479-3075
Fax Number	:	833-914-0407

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/19/2006
Last Update Date	:	06/28/2023

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