Provider Demographics
NPI:1235656919
Name:SMITH, JORDAN (LPN)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3957 DEAN RD
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:NY
Mailing Address - Zip Code:14505-9637
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3957 DEAN RD
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:NY
Practice Address - Zip Code:14505
Practice Address - Country:US
Practice Address - Phone:315-690-1217
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-24
Last Update Date:2017-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY327810-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse