Provider Demographics
NPI:1639564313
Name:JORDAN, JUDY ANN (RN)
Entity Type:Individual
Prefix:
First Name:JUDY
Middle Name:ANN
Last Name:JORDAN
Suffix:
Gender:F
Credentials:RN
Other - Prefix:MISS
Other - First Name:JUDY
Other - Middle Name:ANN
Other - Last Name:LYLES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2205 W 36TH AVE
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:KS
Mailing Address - Zip Code:66103-2107
Mailing Address - Country:US
Mailing Address - Phone:913-956-5620
Mailing Address - Fax:
Practice Address - Street 1:7321 NW 79TH ST
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64152-2150
Practice Address - Country:US
Practice Address - Phone:816-853-9354
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-31
Last Update Date:2015-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010024055163W00000X
KS14-130459-062163WP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100098080AMedicaid
KS100098080AMedicaid