Provider Demographics
NPI:1417778333
Name:JORDAN, CARISSA RENAE (FNP-C)
Entity type:Individual
Prefix:
First Name:CARISSA
Middle Name:RENAE
Last Name:JORDAN
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:755 N 11TH ST STE P3200
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77702-1518
Mailing Address - Country:US
Mailing Address - Phone:409-899-4111
Mailing Address - Fax:
Practice Address - Street 1:755 N 11TH ST STE P3200
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77702-1518
Practice Address - Country:US
Practice Address - Phone:409-899-4111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-23
Last Update Date:2025-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1178703363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily