Provider Demographics
NPI:1184082083
Name:FONTES, JORDAN (NP-C)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:FONTES
Suffix:
Gender:M
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5571 VININGBROOK DR
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:OH
Mailing Address - Zip Code:43016-7162
Mailing Address - Country:US
Mailing Address - Phone:419-989-7181
Mailing Address - Fax:
Practice Address - Street 1:2800 WEST BROAD ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43204
Practice Address - Country:US
Practice Address - Phone:614-274-4171
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-05
Last Update Date:2016-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA 18633-NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily