Healthcare Provider Details

I. General information

NPI: 1104609965
Provider Name (Legal Business Name): HEATHER JORDAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2023
Last Update Date: 04/07/2025
Certification Date: 04/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 N 3RD ST
LONGVIEW TX
75601-6546
US

IV. Provider business mailing address

582 COUNTY ROAD 307
DE BERRY TX
75639-3020
US

V. Phone/Fax

Practice location:
  • Phone: 903-475-3474
  • Fax: 903-367-0300
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1130883
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: