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General NPI Number Information
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NPI Number | 1609482231
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Entity Type | Individual
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Provider Name | CRYSTAL LYNN JORDAN APRN, NP, PMHNP-BC
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Gender | Female
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Dates
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Enumeration Date | 09/18/2020
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Last Update Date | 09/18/2020
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Provider Practice Location Address
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Address Line | 638 OAKBROOK AVE
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City | CHATHAM
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State | IL
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Zip | 62629
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Country | US
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Telephone | 217-553-2815
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 522
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City | CHATHAM
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State | IL
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Zip | 62629-0522
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Country | US
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Telephone | 217-553-2815
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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 | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number | 2020025752
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License Number State | MO
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Taxonomy #2
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number | 209021748
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License Number State | IL
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