Provider Demographics
NPI:1063309243
Name:JORDAN, JACKIE
Entity type:Individual
Prefix:
First Name:JACKIE
Middle Name:
Last Name:JORDAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 S PARK ST
Mailing Address - Street 2:
Mailing Address - City:HOOPER
Mailing Address - State:NE
Mailing Address - Zip Code:68031-3116
Mailing Address - Country:US
Mailing Address - Phone:402-317-8450
Mailing Address - Fax:
Practice Address - Street 1:320 N MAIN ST
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:NE
Practice Address - Zip Code:68025-5058
Practice Address - Country:US
Practice Address - Phone:402-933-0680
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-20
Last Update Date:2025-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant