Basic Information
| Provider Information | |||||||||
| NPI: | 1750613980 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOUNT | ||||||||
| FirstName: | JORDAN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | CRNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 140 WOODLYN AVE | ||||||||
| Address2: | |||||||||
| City: | WILLOW GROVE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190903736 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2677020323 | ||||||||
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| Practice Location | |||||||||
| Address1: | 505 NE 87TH AVE STE 301 | ||||||||
| Address2: | |||||||||
| City: | VANCOUVER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986641965 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3605141854 | ||||||||
| FaxNumber: | 3605146063 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/15/2010 | ||||||||
| LastUpdateDate: | 11/18/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | SP010707 | PA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | MM2292186 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 1021036480001 | 05 | PA | MEDICAID |