=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912487901
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JORDAN FAIN
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/19/2018
-----------------------------------------------------
Last Update Date | 08/19/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 400 TAYLOR RD
-----------------------------------------------------
City | MONTGOMERY
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36117-3512
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 334-213-6255
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 254 DEBBIE DR
-----------------------------------------------------
City | DEATSVILLE
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36022-2567
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
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 | 1-140564
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------