Provider Demographics
NPI:1700513637
Name:SMITH, JORDAN MARIA (FNP)
Entity Type:Individual
Prefix:MS
First Name:JORDAN
Middle Name:MARIA
Last Name:SMITH
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 60352
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63160-0352
Mailing Address - Country:US
Mailing Address - Phone:314-454-8304
Mailing Address - Fax:314-454-5902
Practice Address - Street 1:11133 DUNN RD
Practice Address - Street 2:DIV IM BONE MARROW TRANSPLANT
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63136-6163
Practice Address - Country:US
Practice Address - Phone:314-454-8304
Practice Address - Fax:314-454-5902
Is Sole Proprietor?:No
Enumeration Date:2022-08-02
Last Update Date:2024-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2023019714363LF0000X
IL209025598363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO420129019Medicaid