Provider Demographics
NPI:1093456394
Name:WEAVER, JORDAN MATTHEW (RN)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:MATTHEW
Last Name:WEAVER
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:459 KENNARD RD APT 8
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:NH
Mailing Address - Zip Code:03104-4010
Mailing Address - Country:US
Mailing Address - Phone:510-931-0279
Mailing Address - Fax:
Practice Address - Street 1:250 PLEASANT ST
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NH
Practice Address - Zip Code:03301-2598
Practice Address - Country:US
Practice Address - Phone:603-225-2711
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-02
Last Update Date:2022-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH087160-21163W00000X
CA95145527163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse