Healthcare Provider Details

I. General information

NPI: 1154204378
Provider Name (Legal Business Name): JORDAN KATSUMI KRUSE RN, FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2025
Last Update Date: 07/26/2025
Certification Date: 07/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1245 S MAIN ST
WILLITS CA
95490-4305
US

IV. Provider business mailing address

31262 PUDDING CREEK RD UNIT B
FORT BRAGG CA
95437-8155
US

V. Phone/Fax

Practice location:
  • Phone: 760-496-8102
  • Fax:
Mailing address:
  • Phone: 760-496-8102
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number95030155
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number95135914
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: