Provider Demographics
NPI:1053947135
Name:JORDAN, PENNY MICHELE (RN)
Entity type:Individual
Prefix:
First Name:PENNY
Middle Name:MICHELE
Last Name:JORDAN
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12500 SUMMERWOOD DR
Mailing Address - Street 2:
Mailing Address - City:BURLESON
Mailing Address - State:TX
Mailing Address - Zip Code:76028-7076
Mailing Address - Country:US
Mailing Address - Phone:817-832-0243
Mailing Address - Fax:
Practice Address - Street 1:12500 SUMMERWOOD DR
Practice Address - Street 2:
Practice Address - City:BURLESON
Practice Address - State:TX
Practice Address - Zip Code:76028-7076
Practice Address - Country:US
Practice Address - Phone:817-832-0243
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-20
Last Update Date:2020-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX931341163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse