Provider Demographics
NPI:1023671732
Name:JORDAN, MINERVA (REGISTERED NURSE)
Entity type:Individual
Prefix:MRS
First Name:MINERVA
Middle Name:
Last Name:JORDAN
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4321 ELIOT CT
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95356-8936
Mailing Address - Country:US
Mailing Address - Phone:209-595-8396
Mailing Address - Fax:
Practice Address - Street 1:4321 ELIOT CT
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95356-8936
Practice Address - Country:US
Practice Address - Phone:209-595-8396
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-18
Last Update Date:2019-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA836048163WP0807X, 163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
No163WP0807XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Child & Adolescent