Provider Demographics
NPI:1528597028
Name:LONGNECKER, JORDAN M (NP)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:M
Last Name:LONGNECKER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:1509 DULLES DR
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70506-3718
Mailing Address - Country:US
Mailing Address - Phone:337-991-9276
Mailing Address - Fax:337-943-0846
Practice Address - Street 1:609 SW 8TH ST FL 6
Practice Address - Street 2:
Practice Address - City:BENTONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72712-7886
Practice Address - Country:US
Practice Address - Phone:337-991-9276
Practice Address - Fax:337-943-0846
Is Sole Proprietor?:No
Enumeration Date:2017-06-08
Last Update Date:2017-06-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ARA005126363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily