Healthcare Provider Details

I. General information

NPI: 1942983689
Provider Name (Legal Business Name): JORDAN JAMES AHL CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/09/2023
Last Update Date: 09/20/2023
Certification Date: 09/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2700 W NORFOLK AVE
NORFOLK NE
68701-4438
US

IV. Provider business mailing address

56656 HIGHWAY 136
FAIRBURY NE
68352-5070
US

V. Phone/Fax

Practice location:
  • Phone: 402-371-4880
  • Fax:
Mailing address:
  • Phone: 402-587-1252
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number101801
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: