Basic Information
| Provider Information | |||||||||
| NPI: | 1558957456 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CROUCH | ||||||||
| FirstName: | JORDAN | ||||||||
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| Credential: | DNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 670531 | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452670531 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 234 GOODMAN ST | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452192364 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5135841000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/15/2020 | ||||||||
| LastUpdateDate: | 02/15/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 02/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 367500000X | 0020256 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.