=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588165724
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RACHEL ELAINE JORDAN NURSE PRACTITIONER
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/22/2018
-----------------------------------------------------
Last Update Date | 09/26/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 90 RITCHIE HWY
-----------------------------------------------------
City | PASADENA
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21122-4303
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 443-837-3376
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12116 ELMWOOD DR
-----------------------------------------------------
City | BRANDYWINE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20613-5728
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-452-0657
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | RN1033171
-----------------------------------------------------
License Number State | DC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | R217895
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------