Provider Demographics
NPI:1386461721
Name:JORDAN, AMANDA ROSE (RN, IBCLC)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:ROSE
Last Name:JORDAN
Suffix:
Gender:F
Credentials:RN, IBCLC
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:ROSE
Other - Last Name:FERNANDEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN, IBCLC
Mailing Address - Street 1:277 MOUNT PLEASANT AVE
Mailing Address - Street 2:
Mailing Address - City:WALLINGTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07057-2001
Mailing Address - Country:US
Mailing Address - Phone:845-558-9281
Mailing Address - Fax:
Practice Address - Street 1:277 MOUNT PLEASANT AVE
Practice Address - Street 2:
Practice Address - City:WALLINGTON
Practice Address - State:NJ
Practice Address - Zip Code:07057-2001
Practice Address - Country:US
Practice Address - Phone:845-558-9281
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-25
Last Update Date:2024-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY689755163WN0002X, 163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant
No163WN0002XNursing Service ProvidersRegistered NurseNeonatal Intensive Care