Provider Demographics
NPI:1154204378
Name:KRUSE, JORDAN KATSUMI (RN, FNP)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:KATSUMI
Last Name:KRUSE
Suffix:
Gender:M
Credentials:RN, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31262 PUDDING CREEK RD UNIT B
Mailing Address - Street 2:
Mailing Address - City:FORT BRAGG
Mailing Address - State:CA
Mailing Address - Zip Code:95437-8155
Mailing Address - Country:US
Mailing Address - Phone:760-496-8102
Mailing Address - Fax:
Practice Address - Street 1:1245 S MAIN ST
Practice Address - Street 2:
Practice Address - City:WILLITS
Practice Address - State:CA
Practice Address - Zip Code:95490-4305
Practice Address - Country:US
Practice Address - Phone:760-496-8102
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-07-26
Last Update Date:2025-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95135914163WG0000X
CA95030155363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice