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General NPI Number Information
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NPI Number | 1538893383
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Entity Type | Individual
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Provider Name | JORDAN GREEN FNP
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Gender | Male
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Dates
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Enumeration Date | 07/15/2022
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Last Update Date | 03/10/2023
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Provider Practice Location Address
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Address Line | 515 S ARCHIE ST
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City | VIDOR
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State | TX
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Zip | 77662-4868
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Country | US
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Telephone | 409-769-2295
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Fax |
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Provider Business Mailing Address
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Address Line | 538 BROADWAY
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City | WINNIE
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State | TX
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Zip | 77665-7600
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Country | US
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Telephone | 409-296-6000
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 1110911
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License Number State | TX
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