Healthcare Provider Details

I. General information

NPI: 1275923203
Provider Name (Legal Business Name): JORDAN RICHARD DODGE CNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/29/2015
Last Update Date: 03/28/2023
Certification Date: 03/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 N PICKAWAY ST
CIRCLEVILLE OH
43113-1447
US

IV. Provider business mailing address

PO BOX 7527
DUBLIN OH
43017-0727
US

V. Phone/Fax

Practice location:
  • Phone: 614-566-8333
  • Fax: 614-566-5189
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN.CNP.17030
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: