Healthcare Provider Details

I. General information

NPI: 1932572393
Provider Name (Legal Business Name): JENNA JORDAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNA KINSINGER

II. Dates (important events)

Enumeration Date: 11/07/2015
Last Update Date: 05/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16555 MANCHESTER RD SUITE 100
WILDWOOD MO
63040-1220
US

IV. Provider business mailing address

16555 MANCHESTER RD SUITE 100
WILDWOOD MO
63040-1220
US

V. Phone/Fax

Practice location:
  • Phone: 636-458-0646
  • Fax:
Mailing address:
  • Phone: 636-458-0646
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number2015032917
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number2015010970
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: