Provider Demographics
NPI:1679033476
Name:JORDAN, CHARLES (FNP-C)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:
Last Name:JORDAN
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2350 HIGHWAY 16
Mailing Address - Street 2:
Mailing Address - City:DE LEON
Mailing Address - State:TX
Mailing Address - Zip Code:76444-6411
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2108 W WASHINGTON ST STE 100
Practice Address - Street 2:
Practice Address - City:STEPHENVILLE
Practice Address - State:TX
Practice Address - Zip Code:76401-3928
Practice Address - Country:US
Practice Address - Phone:254-587-3848
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-20
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX848612363LF0000X
TXAP141070363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1679033476Medicaid