=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932572393
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JENNA JORDAN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/07/2015
-----------------------------------------------------
Last Update Date | 05/26/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 16555 MANCHESTER RD SUITE 100
-----------------------------------------------------
City | WILDWOOD
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63040-1220
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 636-458-0646
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 16555 MANCHESTER RD SUITE 100
-----------------------------------------------------
City | WILDWOOD
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63040-1220
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 636-458-0646
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LA2200X
-----------------------------------------------------
Taxonomy Name | Adult Health Nurse Practitioner
-----------------------------------------------------
License Number | 2015032917
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 163W00000X
-----------------------------------------------------
Taxonomy Name | Registered Nurse
-----------------------------------------------------
License Number | 2015010970
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------