Provider Demographics
NPI:1891185674
Name:JORDAN, JENNIFER L (DNP)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:L
Last Name:JORDAN
Suffix:
Gender:F
Credentials:DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 COLLEGE HWY
Mailing Address - Street 2:
Mailing Address - City:SOUTHWICK
Mailing Address - State:MA
Mailing Address - Zip Code:01077
Mailing Address - Country:US
Mailing Address - Phone:413-360-8303
Mailing Address - Fax:413-225-8397
Practice Address - Street 1:800 COLLEGE HWY
Practice Address - Street 2:
Practice Address - City:SOUTHWICK
Practice Address - State:MA
Practice Address - Zip Code:01077
Practice Address - Country:US
Practice Address - Phone:413-360-8303
Practice Address - Fax:413-225-8397
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-30
Last Update Date:2024-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2286670363LF0000X, 163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1891185674Medicaid