Provider Demographics
NPI:1629812771
Name:JORDAN, SHANNON NICHOLE (FNP-C)
Entity type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:NICHOLE
Last Name:JORDAN
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:MRS
Other - First Name:SHANNON
Other - Middle Name:NICHOLE
Other - Last Name:HUDSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6915 CRUMPLER BLVD STE C
Mailing Address - Street 2:
Mailing Address - City:OLIVE BRANCH
Mailing Address - State:MS
Mailing Address - Zip Code:38654-1907
Mailing Address - Country:US
Mailing Address - Phone:662-874-5929
Mailing Address - Fax:
Practice Address - Street 1:6915 CRUMPLER BLVD STE C
Practice Address - Street 2:
Practice Address - City:OLIVE BRANCH
Practice Address - State:MS
Practice Address - Zip Code:38654-1907
Practice Address - Country:US
Practice Address - Phone:662-874-5929
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-24
Last Update Date:2025-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS906721363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily