Provider Demographics
NPI:1477088292
Name:PRIEBE, JORDAN (NP)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:PRIEBE
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 PINEWOOD LN
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:IL
Mailing Address - Zip Code:62298-2020
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1000 ELEVEN S
Practice Address - Street 2:SUITE 1A
Practice Address - City:COLUMBIA
Practice Address - State:IL
Practice Address - Zip Code:62236-1077
Practice Address - Country:US
Practice Address - Phone:618-281-8400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-30
Last Update Date:2017-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209015908363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily