Healthcare Provider Details

I. General information

NPI: 1518610831
Provider Name (Legal Business Name): JORDAN PERI DAIL HEAD FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/27/2022
Last Update Date: 01/27/2022
Certification Date: 01/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1108B KINGOLD BLVD
SNOW HILL NC
28580-1619
US

IV. Provider business mailing address

1108B KINGOLD BLVD
SNOW HILL NC
28580-1619
US

V. Phone/Fax

Practice location:
  • Phone: 252-747-2204
  • Fax: 252-747-2210
Mailing address:
  • Phone: 252-747-2204
  • Fax: 252-747-2210

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number5015686
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: