Provider Demographics
NPI:1467069179
Name:JORDAN, JARICA
Entity type:Individual
Prefix:
First Name:JARICA
Middle Name:
Last Name:JORDAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:144 RIVERVIEW DR
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:IL
Mailing Address - Zip Code:61230-9748
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:303 N JACKSON ST
Practice Address - Street 2:
Practice Address - City:MORRISON
Practice Address - State:IL
Practice Address - Zip Code:61270-3042
Practice Address - Country:US
Practice Address - Phone:815-772-4003
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-26
Last Update Date:2025-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA159880363L00000X
IL209.031471363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner