Provider Demographics
NPI:1730558834
Name:JORDAN, JACQUITA (FNP-BC, AGACNP)
Entity type:Individual
Prefix:
First Name:JACQUITA
Middle Name:
Last Name:JORDAN
Suffix:
Gender:F
Credentials:FNP-BC, AGACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10265 ROLLING RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80925-9509
Mailing Address - Country:US
Mailing Address - Phone:719-653-7776
Mailing Address - Fax:719-726-0002
Practice Address - Street 1:1259 LAKE PLAZA DR STE 270
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80906-3560
Practice Address - Country:US
Practice Address - Phone:719-653-7776
Practice Address - Fax:719-207-7783
Is Sole Proprietor?:No
Enumeration Date:2015-09-18
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COAPN.0991885-NP207QA0401X, 363LA2100X, 363LP0808X
CO0991885363LA2200X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO42820065Medicaid
CO9000108092Medicaid