Provider Demographics
NPI:1083211544
Name:JORDAN, RAVEN (FNP)
Entity Type:Individual
Prefix:
First Name:RAVEN
Middle Name:
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 1:18 GRANGER CT
Mailing Address - Street 2:
Mailing Address - City:BARBOURVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40906-7212
Mailing Address - Country:US
Mailing Address - Phone:606-627-4235
Mailing Address - Fax:
Practice Address - Street 1:215 N ALLISON AVE
Practice Address - Street 2:
Practice Address - City:BARBOURVILLE
Practice Address - State:KY
Practice Address - Zip Code:40906-1336
Practice Address - Country:US
Practice Address - Phone:606-546-9287
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-07
Last Update Date:2021-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3015160363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner