Basic Information
| Provider Information | |||||||||
| NPI: | 1922317619 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JORDAN | ||||||||
| FirstName: | EMILY | ||||||||
| MiddleName: | MICHELLE | ||||||||
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| Credential: | ARNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15 REGIONAL DR | ||||||||
| Address2: | |||||||||
| City: | PINEHURST | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283748850 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9102955511 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 15 REGIONAL DR | ||||||||
| Address2: | |||||||||
| City: | PINEHURST | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283748850 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9102955511 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/29/2010 | ||||||||
| LastUpdateDate: | 04/02/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 6622P | KY | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LP2300X | 3006622 | KY | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care | 363L00000X | 5014262 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 7100140270 | 05 | KY | MEDICAID |