Provider Demographics
NPI:1750575064
Name:JORDAN, CRYSTAL D (APRN)
Entity type:Individual
Prefix:MS
First Name:CRYSTAL
Middle Name:D
Last Name:JORDAN
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:CRYSTAL
Other - Middle Name:DAWN
Other - Last Name:BRELAND
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:ARNP
Mailing Address - Street 1:1114 THOMASVILLE ROAD SUITE E-1
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32303
Mailing Address - Country:US
Mailing Address - Phone:850-771-5765
Mailing Address - Fax:850-779-4744
Practice Address - Street 1:1114 THOMASVILLE ROAD SUITE E-1
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32303
Practice Address - Country:US
Practice Address - Phone:850-771-5765
Practice Address - Fax:850-779-4744
Is Sole Proprietor?:No
Enumeration Date:2007-08-29
Last Update Date:2023-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP3017962363LF0000X
FL3017962163WE0003X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WE0003XNursing Service ProvidersRegistered NurseEmergency
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL308624100Medicaid
FL99388OtherMEDICARE PART B (GROUP ASSOCIATION)
FLAG136ZMedicare PIN
FL308624100Medicaid