Provider Demographics
NPI:1720852650
Name:NELSON, JORDAN ROBERT
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:ROBERT
Last Name:NELSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1597 WARREN RD
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44107-4025
Mailing Address - Country:US
Mailing Address - Phone:262-498-2311
Mailing Address - Fax:
Practice Address - Street 1:3569 RIDGE RD
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44102-5443
Practice Address - Country:US
Practice Address - Phone:216-281-0872
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-10
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN.478554163W00000X
OHAPRN.CNP.0035730363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse