Basic Information
Provider Information | |||||||||
NPI: | 1366524365 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | JORDAN | ||||||||
FirstName: | MICHELL | ||||||||
MiddleName: | M | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | CRNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 920 ELKRIDGE LANDING RD | ||||||||
Address2: |   | ||||||||
City: | LINTHICUM | ||||||||
State: | MD | ||||||||
PostalCode: | 210902917 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4434625010 | ||||||||
FaxNumber: | 4106842031 | ||||||||
Practice Location | |||||||||
Address1: | 2540 CENTREVILLE RD | ||||||||
Address2: |   | ||||||||
City: | CENTREVILLE | ||||||||
State: | MD | ||||||||
PostalCode: | 21617 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4117584432 | ||||||||
FaxNumber: | 4107581938 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/19/2006 | ||||||||
LastUpdateDate: | 11/20/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | R197956 | MD | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   |
ID Information
ID | Type | State | Issuer | Description | 68320014 | 01 |   | BCBD FEDERAL | OTHER | 97602401 | 01 |   | BCBS MD | OTHER | 8355618 | 01 |   | AETNA HMO | OTHER | 0009541449 | 01 |   | AETNA PPO | OTHER | 049008300 | 05 | MD |   | MEDICAID |