Healthcare Provider Details

I. General information

NPI: 1750613980
Provider Name (Legal Business Name): JORDAN MOUNT CRNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/15/2010
Last Update Date: 11/18/2020
Certification Date: 11/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 NE 87TH AVE STE 301
VANCOUVER WA
98664-1965
US

IV. Provider business mailing address

140 WOODLYN AVE
WILLOW GROVE PA
19090-3736
US

V. Phone/Fax

Practice location:
  • Phone: 360-514-1854
  • Fax: 360-514-6063
Mailing address:
  • Phone: 267-702-0323
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberSP010707
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberMM2292186
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: