Provider Demographics
NPI:1639934102
Name:BACK, LORI JORDAN (FNP-C)
Entity type:Individual
Prefix:
First Name:LORI
Middle Name:JORDAN
Last Name:BACK
Suffix:
Gender:
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4540 SOUTHSIDE BLVD STE 401
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-5488
Mailing Address - Country:US
Mailing Address - Phone:904-977-6380
Mailing Address - Fax:800-983-7668
Practice Address - Street 1:5880 49TH ST N UNIT N-201
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33709-2150
Practice Address - Country:US
Practice Address - Phone:727-300-0405
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-14
Last Update Date:2025-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11031278363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily