Provider Demographics
NPI:1972199644
Name:DANIELS, JORDAN NICOLE (FNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:JORDAN
Middle Name:NICOLE
Last Name:DANIELS
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:JORDAN
Other - Middle Name:NICOLE
Other - Last Name:PATRICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1718 PARR AVE STE A
Mailing Address - Street 2:
Mailing Address - City:DYERSBURG
Mailing Address - State:TN
Mailing Address - Zip Code:38024-2075
Mailing Address - Country:US
Mailing Address - Phone:731-285-4104
Mailing Address - Fax:
Practice Address - Street 1:1718 PARR AVE STE A
Practice Address - Street 2:
Practice Address - City:DYERSBURG
Practice Address - State:TN
Practice Address - Zip Code:38024-2075
Practice Address - Country:US
Practice Address - Phone:731-285-4104
Practice Address - Fax:731-285-8157
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-17
Last Update Date:2021-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN188484363LS0200X
TN28834363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
No363LS0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerSchoolGroup - Single Specialty