MEDICARE: ROBERTA MARIE JORDAN CNM, FNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	8127	MN
2	363LF0000X	Family Nurse Practitioner	71012163A	IN
3	363L00000X	Nurse Practitioner	71012163A	IN
4	367A00000X	Advanced Practice Midwife	458	MN
5	367A00000X	Advanced Practice Midwife	4704244874	MI

General Provider Information

NPI Number	:	1649550492
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ROBERTA MARIE JORDAN CNM, FNP

Provider Business Mailing Address
First Line	:	PO BOX 637764
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45263-7764
Country	:	US
Telephone Number	:	317-880-3939
Fax Number	:

Provider Business Practice Location Address
First Line	:	6452 CITY WEST PARKWAY
Second Line	:	NEW KINGDOM HEALTHCARE
City	:	EDEN PRAIRIE
State	:	MN
Zip	:	55344-0010
Country	:	US
Telephone Number	:	952-999-0333
Fax Number	:	952-300-2558

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/25/2011
Last Update Date	:	09/22/2025

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