Provider Demographics
NPI:1043757784
Name:WALD, JORDAN BASS (CRNP)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:BASS
Last Name:WALD
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1575 MONTGOMERY HWY
Mailing Address - Street 2:
Mailing Address - City:VESTAVIA HILLS
Mailing Address - State:AL
Mailing Address - Zip Code:35216-4510
Mailing Address - Country:US
Mailing Address - Phone:205-822-1150
Mailing Address - Fax:205-822-1158
Practice Address - Street 1:1575 MONTGOMERY HWY
Practice Address - Street 2:
Practice Address - City:VESTAVIA HILLS
Practice Address - State:AL
Practice Address - Zip Code:35216-4510
Practice Address - Country:US
Practice Address - Phone:205-822-1150
Practice Address - Fax:205-822-1158
Is Sole Proprietor?:No
Enumeration Date:2017-01-19
Last Update Date:2021-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-135908363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily