Provider Demographics
NPI:1972387504
Name:MANDEVILLE, JORDAN KELLY
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:KELLY
Last Name:MANDEVILLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:61 BOURBAKI RD
Mailing Address - Street 2:
Mailing Address - City:NEW BERLIN
Mailing Address - State:IL
Mailing Address - Zip Code:62670-4570
Mailing Address - Country:US
Mailing Address - Phone:217-801-8732
Mailing Address - Fax:
Practice Address - Street 1:1020 S 5TH ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62703-2312
Practice Address - Country:US
Practice Address - Phone:217-544-3143
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-23
Last Update Date:2023-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209028150363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health