Healthcare Provider Details

I. General information

NPI: 1417348905
Provider Name (Legal Business Name): JEREMY DUGGER JORDAN CRNP, CPNP-AC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/05/2015
Last Update Date: 12/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 7TH AVE S CPPI 102
BIRMINGHAM AL
35233-1711
US

IV. Provider business mailing address

1720 2ND AVE S # NB308
BIRMINGHAM AL
35294-1210
US

V. Phone/Fax

Practice location:
  • Phone: 205-638-3400
  • Fax:
Mailing address:
  • Phone: 205-996-3651
  • Fax: 205-996-7177

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number1-136533
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code363LP0222X
TaxonomyCritical Care Pediatric Nurse Practitioner
License Number1-135633
License Number StateAL
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number1-136533
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: