Healthcare Provider Details

I. General information

NPI: 1639949928
Provider Name (Legal Business Name): JORDAN ELYSE GOODIN FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/08/2024
Last Update Date: 06/29/2026
Certification Date: 06/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

340 KELLEY PKWY
MEXICO MO
65265-3811
US

IV. Provider business mailing address

340 KELLEY PKWY
MEXICO MO
65265-3811
US

V. Phone/Fax

Practice location:
  • Phone: 573-582-1234
  • Fax:
Mailing address:
  • Phone: 573-582-1234
  • Fax: 573-582-1212

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number2018023543
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2024005871
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: