Provider Demographics
NPI:1043852775
Name:EDWARDS, JORDAN LEE (NP-C)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:LEE
Last Name:EDWARDS
Suffix:
Gender:M
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 VININGS BLVD
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:MO
Mailing Address - Zip Code:63366-7582
Mailing Address - Country:US
Mailing Address - Phone:870-634-6883
Mailing Address - Fax:
Practice Address - Street 1:105 CREEKSIDE OFFICE DR
Practice Address - Street 2:
Practice Address - City:WENTZVILLE
Practice Address - State:MO
Practice Address - Zip Code:63385-3289
Practice Address - Country:US
Practice Address - Phone:636-625-5200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-15
Last Update Date:2019-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019026971363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health