Provider Demographics
NPI:1104406909
Name:JORDAN, JENNIFER LYNNE (CNM)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNNE
Last Name:JORDAN
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:LYNNE
Other - Last Name:RILEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:16086 ANNIE DR
Mailing Address - Street 2:
Mailing Address - City:GRASS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95949-7149
Mailing Address - Country:US
Mailing Address - Phone:530-477-8988
Mailing Address - Fax:
Practice Address - Street 1:2025 P ST
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95811-5213
Practice Address - Country:US
Practice Address - Phone:916-936-2229
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-14
Last Update Date:2021-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANMW236171367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
CANMW236171OtherNURSE-MIDWIFE LICENSE