Provider Demographics
NPI:1750613980
Name:MOUNT, JORDAN (CRNP)
Entity type:Individual
Prefix:MR
First Name:JORDAN
Middle Name:
Last Name:MOUNT
Suffix:
Gender:M
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 WOODLYN AVE
Mailing Address - Street 2:
Mailing Address - City:WILLOW GROVE
Mailing Address - State:PA
Mailing Address - Zip Code:19090-3736
Mailing Address - Country:US
Mailing Address - Phone:267-702-0323
Mailing Address - Fax:
Practice Address - Street 1:505 NE 87TH AVE STE 301
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98664-1965
Practice Address - Country:US
Practice Address - Phone:360-514-1854
Practice Address - Fax:360-514-6063
Is Sole Proprietor?:No
Enumeration Date:2010-02-15
Last Update Date:2020-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP010707363LF0000X
WAMM2292186363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1021036480001Medicaid