Healthcare Provider Details

I. General information

NPI: 1508983735
Provider Name (Legal Business Name): CARLA FAE JORDAN RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1407 SAINT ANDREW ST STE 100
LA CROSSE WI
54603-3301
US

IV. Provider business mailing address

2830 WARD AVE
LA CROSSE WI
54601-7426
US

V. Phone/Fax

Practice location:
  • Phone: 608-785-6212
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License Number
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: