Healthcare Provider Details

I. General information

NPI: 1033718077
Provider Name (Legal Business Name): JORDAN BIXBY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/21/2020
Last Update Date: 06/11/2026
Certification Date: 06/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3173 43RD ST S
FARGO ND
58104-4563
US

IV. Provider business mailing address

3173 43RD ST S
FARGO ND
58104-4563
US

V. Phone/Fax

Practice location:
  • Phone: 701-478-8780
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95015695
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: