Healthcare Provider Details

I. General information

NPI: 1730743758
Provider Name (Legal Business Name): JORDAN K PARKER CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2019
Last Update Date: 07/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

969 LAKELAND DR
JACKSON MS
39216-4606
US

IV. Provider business mailing address

PO BOX 4608
JACKSON MS
39296
US

V. Phone/Fax

Practice location:
  • Phone: 601-362-1990
  • Fax:
Mailing address:
  • Phone: 334-279-1450
  • Fax: 334-279-1660

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR901564
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: