Provider Demographics
NPI:1649550492
Name:JORDAN, ROBERTA MARIE (CNM, FNP)
Entity type:Individual
Prefix:
First Name:ROBERTA
Middle Name:MARIE
Last Name:JORDAN
Suffix:
Gender:F
Credentials:CNM, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6452 CITY WEST PARKWAY
Mailing Address - Street 2:NEW KINGDOM HEALTHCARE
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55344-0010
Mailing Address - Country:US
Mailing Address - Phone:952-999-0333
Mailing Address - Fax:952-300-2558
Practice Address - Street 1:6452 CITY WEST PARKWAY
Practice Address - Street 2:NEW KINGDOM HEALTHCARE
Practice Address - City:EDEN PRAIRIE
Practice Address - State:MN
Practice Address - Zip Code:55344-0010
Practice Address - Country:US
Practice Address - Phone:952-999-0333
Practice Address - Fax:952-300-2558
Is Sole Proprietor?:No
Enumeration Date:2011-08-25
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71012163A363LF0000X, 363L00000X
MN8127363LF0000X
MN458367A00000X
MI4704244874367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife