Provider Demographics
NPI:1679153720
Name:STIVERS, JORDAN BROOKE (FNP)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:BROOKE
Last Name:STIVERS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3889
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37602-3889
Mailing Address - Country:US
Mailing Address - Phone:423-794-2457
Mailing Address - Fax:423-283-9480
Practice Address - Street 1:301 MED TECH PKWY STE 240
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-2641
Practice Address - Country:US
Practice Address - Phone:423-794-5520
Practice Address - Fax:423-282-6940
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-13
Last Update Date:2021-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024173715363LF0000X
TN29287363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily