Healthcare Provider Details

I. General information

NPI: 1952718785
Provider Name (Legal Business Name): CATHERINE JORDAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2014
Last Update Date: 10/26/2021
Certification Date: 10/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4850 BROAD RD STE 2C
SYRACUSE NY
13215-5103
US

IV. Provider business mailing address

4850 BROAD RD STE 2C
SYRACUSE NY
13215-5103
US

V. Phone/Fax

Practice location:
  • Phone: 315-492-5915
  • Fax:
Mailing address:
  • Phone: 315-492-5195
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WW0101X
TaxonomyAmbulatory Women's Health Care Registered Nurse
License Number496152
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number421195
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: