Provider Demographics
NPI:1306126263
Name:JORDAN, CHARLES RAYMOND (FNP)
Entity type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:RAYMOND
Last Name:JORDAN
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 395
Mailing Address - Street 2:
Mailing Address - City:N.CARROLLTON
Mailing Address - State:MS
Mailing Address - Zip Code:38947-0395
Mailing Address - Country:US
Mailing Address - Phone:662-466-3632
Mailing Address - Fax:
Practice Address - Street 1:1350 SUNSET DR STE B
Practice Address - Street 2:
Practice Address - City:GRENADA
Practice Address - State:MS
Practice Address - Zip Code:38901-4079
Practice Address - Country:US
Practice Address - Phone:662-466-3632
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-24
Last Update Date:2011-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR869908363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily