Healthcare Provider Details

I. General information

NPI: 1265255475
Provider Name (Legal Business Name): JORDAN TANNER 95091873 RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/05/2024
Last Update Date: 01/08/2026
Certification Date: 01/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10877 CONDUCTOR BLVD STE 300
SUTTER CREEK CA
95685-9688
US

IV. Provider business mailing address

10877 CONDUCTOR BLVD STE 300
SUTTER CREEK CA
95685-9688
US

V. Phone/Fax

Practice location:
  • Phone: 209-223-6412
  • Fax:
Mailing address:
  • Phone: 209-223-6412
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95036141
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: