Healthcare Provider Details

I. General information

NPI: 1316755358
Provider Name (Legal Business Name): JEANIQUE JORDAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/23/2024
Last Update Date: 12/23/2024
Certification Date: 12/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27005 76TH AVE
NEW HYDE PARK NY
11040-1402
US

IV. Provider business mailing address

12111 196TH ST # 2
SPRINGFIELD GARDENS NY
11413-1138
US

V. Phone/Fax

Practice location:
  • Phone: 718-470-7310
  • Fax:
Mailing address:
  • Phone: 617-201-4696
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License Number814550
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: