Healthcare Provider Details

I. General information

NPI: 1619656691
Provider Name (Legal Business Name): JORDYN SAMARA AXELROD NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2023
Last Update Date: 02/09/2024
Certification Date: 02/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4901 LAC DE VILLE BLVD BLDG D
ROCHESTER NY
14618-5647
US

IV. Provider business mailing address

601 ELMWOOD AVE BOX 665
ROCHESTER NY
14642-0001
US

V. Phone/Fax

Practice location:
  • Phone: 585-406-0267
  • Fax:
Mailing address:
  • Phone: 585-275-5321
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WX0800X
TaxonomyOrthopedic Registered Nurse
License Number764789
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number352760
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: