Provider Demographics
NPI:1770365272
Name:CONSTANCE W JORDAN ANP PMHNP PLLC
Entity type:Organization
Organization Name:CONSTANCE W JORDAN ANP PMHNP PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING AGENT
Authorized Official - Prefix:
Authorized Official - First Name:CHERYL
Authorized Official - Middle Name:
Authorized Official - Last Name:MCATEE-THORNTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-452-4420
Mailing Address - Street 1:305 COMMERCIAL ST STE 103
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04101-5625
Mailing Address - Country:US
Mailing Address - Phone:207-747-5958
Mailing Address - Fax:
Practice Address - Street 1:962 SHORE RD
Practice Address - Street 2:
Practice Address - City:CAPE ELIZABETH
Practice Address - State:ME
Practice Address - Zip Code:04107-1516
Practice Address - Country:US
Practice Address - Phone:207-747-5958
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-18
Last Update Date:2024-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center