Healthcare Provider Details

I. General information

NPI: 1689280034
Provider Name (Legal Business Name): JORDAN NASH-BOULDEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/21/2020
Last Update Date: 09/21/2020
Certification Date: 09/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6000 S LAKESHORE DR
TEMPE AZ
85283-3049
US

IV. Provider business mailing address

29210 N 50TH PL
CAVE CREEK AZ
85331-2349
US

V. Phone/Fax

Practice location:
  • Phone: 480-838-3200
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: