Provider Demographics
NPI:1477561991
Name:JORDAN, MARY (CPNP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:JORDAN
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2001 BLOOMINGTON AVENUE S
Mailing Address - Street 2:COMMUNITY-UNIVERSITY HEALTH CARE CENTER
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55404-3074
Mailing Address - Country:US
Mailing Address - Phone:612-638-0700
Mailing Address - Fax:
Practice Address - Street 1:2001 BLOOMINGTON AVENUE S
Practice Address - Street 2:COMMUNITY-UNIVERSITY HEALTH CARE CENTER
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55404-3074
Practice Address - Country:US
Practice Address - Phone:612-638-0700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR125380-1363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN500002019Medicare ID - Type Unspecified
MNS97874Medicare UPIN