Provider Demographics
NPI:1710044474
Name:JORDAN, AMANDA T (OGNP)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:T
Last Name:JORDAN
Suffix:
Gender:F
Credentials:OGNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7510 MOAK RD
Mailing Address - Street 2:
Mailing Address - City:SUMMIT
Mailing Address - State:MS
Mailing Address - Zip Code:39666-7580
Mailing Address - Country:US
Mailing Address - Phone:601-684-1205
Mailing Address - Fax:601-684-1205
Practice Address - Street 1:114 E PRESLEY BLVD
Practice Address - Street 2:
Practice Address - City:MCCOMB
Practice Address - State:MS
Practice Address - Zip Code:39648-5908
Practice Address - Country:US
Practice Address - Phone:601-684-1030
Practice Address - Fax:601-684-5999
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR575623363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00124011Medicaid
MS500001421Medicare ID - Type Unspecified
MSQ06395Medicare UPIN