Provider Demographics
NPI:1003913799
Name:JORDAN, SUSAN E (APN)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:E
Last Name:JORDAN
Suffix:
Gender:F
Credentials:APN
Other - Prefix:MISS
Other - First Name:SUSAN
Other - Middle Name:E
Other - Last Name:KURTZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:707 N LOGAN AVENUE
Mailing Address - Street 2:DANVILLE POLYCLINIC, LTD.
Mailing Address - City:DANVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:61832-4360
Mailing Address - Country:US
Mailing Address - Phone:217-477-4720
Mailing Address - Fax:217-477-4758
Practice Address - Street 1:707 N LOGAN AVENUE
Practice Address - Street 2:DANVILLE POLYCLINIC, LTD.
Practice Address - City:DANVILLE
Practice Address - State:IL
Practice Address - Zip Code:61832-4360
Practice Address - Country:US
Practice Address - Phone:217-477-4720
Practice Address - Fax:217-477-4758
Is Sole Proprietor?:No
Enumeration Date:2006-09-17
Last Update Date:2015-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209004797363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209004797Medicaid
IL209004797Medicaid
Q24232Medicare UPIN