Healthcare Provider Details

I. General information

NPI: 1790622744
Provider Name (Legal Business Name): JORDAN HARE APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/29/2026
Last Update Date: 04/29/2026
Certification Date: 04/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 PIN OAK LN
KEYSER WV
26726-5908
US

IV. Provider business mailing address

511 VALENTINE AVE
CUMBERLAND MD
21502-1245
US

V. Phone/Fax

Practice location:
  • Phone: 304-597-3500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number125973
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: