Provider Demographics
NPI:1073285573
Name:JORDAN, MALLORY ODOM (FNP)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:ODOM
Last Name:JORDAN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27 S SIXTH ST
Mailing Address - Street 2:
Mailing Address - City:BAY SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:39422-9052
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:27 S SIXTH ST
Practice Address - Street 2:
Practice Address - City:BAY SPRINGS
Practice Address - State:MS
Practice Address - Zip Code:39422-9052
Practice Address - Country:US
Practice Address - Phone:601-764-2155
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-02
Last Update Date:2021-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS904891363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily