Healthcare Provider Details

I. General information

NPI: 1750952867
Provider Name (Legal Business Name): JORDAN DIANA AGNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/09/2021
Last Update Date: 08/26/2021
Certification Date: 08/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7630 SOUTHERN BLVD
YOUNGSTOWN OH
44512-5633
US

IV. Provider business mailing address

7630 SOUTHERN BLVD
YOUNGSTOWN OH
44512-5633
US

V. Phone/Fax

Practice location:
  • Phone: 330-729-8000
  • Fax:
Mailing address:
  • Phone: 330-729-8000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberAPRN.CNP.0029271
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAPRN.CNP.0029271
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code364SA2200X
TaxonomyAdult Health Clinical Nurse Specialist
License NumberAPRN.CNP.0029271
License Number StateOH
# 4
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: