Provider Demographics
NPI:1275249237
Name:JORDAN, ANTIONETTE
Entity Type:Individual
Prefix:
First Name:ANTIONETTE
Middle Name:
Last Name:JORDAN
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:PO BOX 802841
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64180-2841
Mailing Address - Country:US
Mailing Address - Phone:314-842-9669
Mailing Address - Fax:314-842-1017
Practice Address - Street 1:10004 KENNERLY RD STE 374B
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63128-2178
Practice Address - Country:US
Practice Address - Phone:314-842-9669
Practice Address - Fax:314-842-1017
Is Sole Proprietor?:No
Enumeration Date:2023-01-24
Last Update Date:2023-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2022047351363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2022047351OtherLICENSE
MO420120169Medicaid