Healthcare Provider Details

I. General information

NPI: 1457383606
Provider Name (Legal Business Name): JAY DANIEL JORDAN CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 10/27/2020
Certification Date: 10/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

612 MOCKSVILLE AVE
SALISBURY NC
28144-2732
US

IV. Provider business mailing address

4605 MEETING HOUSE LN
CLEMMONS NC
27012-7706
US

V. Phone/Fax

Practice location:
  • Phone: 704-210-5661
  • Fax: 704-210-5660
Mailing address:
  • Phone: 336-778-1879
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number47466
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: