Provider Demographics
NPI:1578014403
Name:JORDAN, MARIO (APRN, PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:MARIO
Middle Name:
Last Name:JORDAN
Suffix:
Gender:M
Credentials:APRN, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12900 LAKE AVE APT 1101
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44107-1552
Mailing Address - Country:US
Mailing Address - Phone:216-269-8527
Mailing Address - Fax:
Practice Address - Street 1:12900 LAKE AVE APT 1101
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:OH
Practice Address - Zip Code:44107-1552
Practice Address - Country:US
Practice Address - Phone:216-269-8527
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-14
Last Update Date:2023-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.0034613363LP0808X
OHRN416819163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse