Healthcare Provider Details

I. General information

NPI: 1245913367
Provider Name (Legal Business Name): JORDAN FREDERICK CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2023
Last Update Date: 08/08/2023
Certification Date: 08/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 BOB LAWRENCE DR
WINFIELD AL
35594-0019
US

IV. Provider business mailing address

PO BOX 1140
WINFIELD AL
35594-1140
US

V. Phone/Fax

Practice location:
  • Phone: 205-487-4535
  • Fax: 205-487-8827
Mailing address:
  • Phone: 205-487-4535
  • Fax: 205-487-8827

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number1155321
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: