Provider Demographics
NPI:1003255266
Name:JORDAN, CRYSTAL MARIE
Entity Type:Individual
Prefix:MRS
First Name:CRYSTAL
Middle Name:MARIE
Last Name:JORDAN
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:CRYSTAL
Other - Middle Name:MARIE
Other - Last Name:COLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:901 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:OH
Mailing Address - Zip Code:45662-3944
Mailing Address - Country:US
Mailing Address - Phone:740-354-7702
Mailing Address - Fax:740-353-1662
Practice Address - Street 1:901 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:OH
Practice Address - Zip Code:45662-3944
Practice Address - Country:US
Practice Address - Phone:740-354-1010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-20
Last Update Date:2022-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA.14867-NP363LF0000X
OHAPRN.CNP.14867363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily