Provider Demographics
NPI:1629518626
Name:JORDAN, MARY ELISABETH (FNP-C)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:ELISABETH
Last Name:JORDAN
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:BETH
Other - Middle Name:
Other - Last Name:JORDAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:FNP-C
Mailing Address - Street 1:4665 MAIN ST SUITE 2
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:TN
Mailing Address - Zip Code:37347
Mailing Address - Country:US
Mailing Address - Phone:423-942-0145
Mailing Address - Fax:423-942-0146
Practice Address - Street 1:4665 MAIN ST SUITE 2
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:TN
Practice Address - Zip Code:37347
Practice Address - Country:US
Practice Address - Phone:423-942-0145
Practice Address - Fax:423-942-0146
Is Sole Proprietor?:No
Enumeration Date:2017-02-24
Last Update Date:2021-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN22310363LF0000X, 364SF0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SF0001XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistFamily Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily