Provider Demographics
NPI:1497285977
Name:HOGAN, JORDAN E
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:E
Last Name:HOGAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JORDAN
Other - Middle Name:E
Other - Last Name:EPPERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1025 MAINE ST
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62301-4038
Mailing Address - Country:US
Mailing Address - Phone:1217-222-6550
Mailing Address - Fax:217-277-2253
Practice Address - Street 1:1118 HAMPSHIRE ST
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:IL
Practice Address - Zip Code:62301-3027
Practice Address - Country:US
Practice Address - Phone:217-222-6550
Practice Address - Fax:217-277-2253
Is Sole Proprietor?:No
Enumeration Date:2017-06-15
Last Update Date:2017-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041415266163WP0000X
IL209016169363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WP0000XNursing Service ProvidersRegistered NursePain Management