Provider Demographics
NPI:1205683984
Name:JORDAN, MYLA (RN)
Entity type:Individual
Prefix:
First Name:MYLA
Middle Name:
Last Name:JORDAN
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 S 5TH ST
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:OR
Mailing Address - Zip Code:97355-2504
Mailing Address - Country:US
Mailing Address - Phone:541-451-8555
Mailing Address - Fax:
Practice Address - Street 1:1700 S 5TH ST
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:OR
Practice Address - Zip Code:97355-2504
Practice Address - Country:US
Practice Address - Phone:541-451-8555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-01
Last Update Date:2024-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201606325RN163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse