Healthcare Provider Details

I. General information

NPI: 1720551567
Provider Name (Legal Business Name): JORDAN SHANAHAN FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/04/2019
Last Update Date: 01/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 N HIGHLAND AVE
AURORA IL
60506-3814
US

IV. Provider business mailing address

400 N HIGHLAND AVE
AURORA IL
60506-3814
US

V. Phone/Fax

Practice location:
  • Phone: 630-892-4355
  • Fax:
Mailing address:
  • Phone: 630-978-2532
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209017719
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: