Healthcare Provider Details

I. General information

NPI: 1972915437
Provider Name (Legal Business Name): JORDAN HAMMOCK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2014
Last Update Date: 06/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

339 WALKER CHAPEL PLZ
FULTONDALE AL
35068-3401
US

IV. Provider business mailing address

79 MEGAN RD
HAYDEN AL
35079-9200
US

V. Phone/Fax

Practice location:
  • Phone: 205-841-2844
  • Fax:
Mailing address:
  • Phone: 205-902-7872
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1-123755
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: