Provider Demographics
NPI:1902974728
Name:JORDAN, BETTY JO (APN)
Entity type:Individual
Prefix:MS
First Name:BETTY
Middle Name:JO
Last Name:JORDAN
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 S WINFREE ST
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:TX
Mailing Address - Zip Code:77535-2945
Mailing Address - Country:US
Mailing Address - Phone:936-257-1102
Mailing Address - Fax:936-257-1109
Practice Address - Street 1:601 S WINFREE ST
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:TX
Practice Address - Zip Code:77535-2945
Practice Address - Country:US
Practice Address - Phone:936-257-1102
Practice Address - Fax:936-257-1109
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-01
Last Update Date:2007-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX509147363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX170714302Medicaid
TX170714301Medicaid
TXNP0425Medicare PIN
TX170714302Medicaid