Provider Demographics
NPI:1083471965
Name:DAVIES, JORDAN CELINE
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:CELINE
Last Name:DAVIES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1850 HOLMAN CITY RD
Mailing Address - Street 2:
Mailing Address - City:CLAYVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13322-1406
Mailing Address - Country:US
Mailing Address - Phone:315-941-6297
Mailing Address - Fax:
Practice Address - Street 1:1424 GENESEE ST
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13502-5192
Practice Address - Country:US
Practice Address - Phone:315-724-6146
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-06
Last Update Date:2024-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF353278-01363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner