Provider Demographics
NPI:1619063674
Name:JORDAN, MEGAN E (NP)
Entity Type:Individual
Prefix:MRS
First Name:MEGAN
Middle Name:E
Last Name:JORDAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:MEGAN
Other - Middle Name:E
Other - Last Name:CAMPBELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:695 TRUMAN PKWY
Mailing Address - Street 2:SUITE 203
Mailing Address - City:HYDE PARK
Mailing Address - State:MA
Mailing Address - Zip Code:02136
Mailing Address - Country:US
Mailing Address - Phone:617-361-1470
Mailing Address - Fax:617-361-9060
Practice Address - Street 1:1353 DORCHESTER AVE
Practice Address - Street 2:
Practice Address - City:DORCHESTER
Practice Address - State:MA
Practice Address - Zip Code:02122-2932
Practice Address - Country:US
Practice Address - Phone:617-288-3230
Practice Address - Fax:617-825-4972
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA258635363LP0200X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAMC0640777IOtherSTATE CONTROLLED LICENSE
MAMC0640777IOtherSTATE CONTROLLED LICENSE