Healthcare Provider Details

I. General information

NPI: 1073303277
Provider Name (Legal Business Name): JORDAN HARLOW NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2025
Last Update Date: 09/05/2025
Certification Date: 09/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

213 N MAIN ST
MOSCOW ID
83843-2700
US

IV. Provider business mailing address

PO BOX 3687
COEUR D ALENE ID
83816-2529
US

V. Phone/Fax

Practice location:
  • Phone: 208-882-7565
  • Fax:
Mailing address:
  • Phone: 208-819-2183
  • Fax: 208-209-6063

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number2171158
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: