Provider Demographics
NPI:1821651571
Name:MOORE, JORDAN RUSSELL
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:RUSSELL
Last Name:MOORE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:206 S MULBERRY ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:OH
Mailing Address - Zip Code:43050-3331
Mailing Address - Country:US
Mailing Address - Phone:740-399-3008
Mailing Address - Fax:
Practice Address - Street 1:206 S MULBERRY ST
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:OH
Practice Address - Zip Code:43050-3331
Practice Address - Country:US
Practice Address - Phone:740-399-3008
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-18
Last Update Date:2019-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.025092363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHAPRN.CNP.025092OtherSTATE LICENSE NUMBER