Provider Demographics
NPI:1164210670
Name:JORDAN, JEREMY VAN (APRN-CNP)
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:VAN
Last Name:JORDAN
Suffix:
Gender:M
Credentials:APRN-CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3851 S COMO AVE
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-1446
Mailing Address - Country:US
Mailing Address - Phone:208-794-7165
Mailing Address - Fax:
Practice Address - Street 1:3851 S COMO AVE
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-1446
Practice Address - Country:US
Practice Address - Phone:208-794-7165
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-26
Last Update Date:2025-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID8671950363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health