Healthcare Provider Details

I. General information

NPI: 1881279693
Provider Name (Legal Business Name): JORDAN MARIE DONOVAN APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/12/2021
Last Update Date: 05/04/2021
Certification Date: 05/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1428 S HAMPTON XING
CAVE SPRINGS AR
72718-5004
US

IV. Provider business mailing address

1428 S HAMPTON XING
CAVE SPRINGS AR
72718-5004
US

V. Phone/Fax

Practice location:
  • Phone: 636-541-9915
  • Fax:
Mailing address:
  • Phone: 636-541-9915
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number215031
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code163WW0000X
TaxonomyWound Care Registered Nurse
License NumberR104095
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: