Healthcare Provider Details

I. General information

NPI: 1225397961
Provider Name (Legal Business Name): JORDAN BLAKE CARMEAN ACNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2012
Last Update Date: 05/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

971 LAKELAND DR STE 1052
JACKSON MS
39216-4609
US

IV. Provider business mailing address

971 LAKELAND DR STE 1052
JACKSON MS
39216-4609
US

V. Phone/Fax

Practice location:
  • Phone: 601-981-9503
  • Fax: 601-982-0148
Mailing address:
  • Phone: 601-981-9503
  • Fax: 601-982-0148

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberR890584
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: