Healthcare Provider Details

I. General information

NPI: 1558294785
Provider Name (Legal Business Name): CRYSTAL JORDAN FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/06/2026
Last Update Date: 06/06/2026
Certification Date: 06/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18496 SKY LN
SAUCIER MS
39574-9686
US

IV. Provider business mailing address

18496 SKY LN
SAUCIER MS
39574-9686
US

V. Phone/Fax

Practice location:
  • Phone: 234-234-2557
  • Fax:
Mailing address:
  • Phone: 228-234-2557
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number3-002718
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number907727
License Number StateMS
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number243168
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: