Provider Demographics
NPI:1942900154
Name:JORDAN, STACI (BSN, RN)
Entity Type:Individual
Prefix:
First Name:STACI
Middle Name:
Last Name:JORDAN
Suffix:
Gender:F
Credentials:BSN, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7994 MUDDY CREEK MOUNTAIN RD
Mailing Address - Street 2:
Mailing Address - City:LEWISBURG
Mailing Address - State:WV
Mailing Address - Zip Code:24901-9650
Mailing Address - Country:US
Mailing Address - Phone:304-661-0735
Mailing Address - Fax:
Practice Address - Street 1:314 GEORGE ST STE 314
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801-2653
Practice Address - Country:US
Practice Address - Phone:304-252-8070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-06
Last Update Date:2023-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV70602163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse