Provider Demographics
NPI:1235929480
Name:KIVRAK, JORDAN CAMILLE (RN, MSN)
Entity type:Individual
Prefix:MRS
First Name:JORDAN
Middle Name:CAMILLE
Last Name:KIVRAK
Suffix:
Gender:F
Credentials:RN, MSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:216 STONE VIEW CT
Mailing Address - Street 2:
Mailing Address - City:FENTON
Mailing Address - State:MO
Mailing Address - Zip Code:63026-5108
Mailing Address - Country:US
Mailing Address - Phone:573-300-1399
Mailing Address - Fax:
Practice Address - Street 1:216 STONE VIEW CT
Practice Address - Street 2:
Practice Address - City:FENTON
Practice Address - State:MO
Practice Address - Zip Code:63026-5108
Practice Address - Country:US
Practice Address - Phone:573-300-1399
Practice Address - Fax:573-300-1399
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-10
Last Update Date:2025-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014019831163WN1003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WN1003XNursing Service ProvidersRegistered NurseNutrition Support