Provider Demographics
NPI:1780429613
Name:LOOSE, JORDAN ELIZABETH (APNP)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:ELIZABETH
Last Name:LOOSE
Suffix:
Gender:F
Credentials:APNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N6291 PAUL RD
Mailing Address - Street 2:
Mailing Address - City:BRILLION
Mailing Address - State:WI
Mailing Address - Zip Code:54110-9428
Mailing Address - Country:US
Mailing Address - Phone:920-901-6066
Mailing Address - Fax:
Practice Address - Street 1:1160 SERVICE RD
Practice Address - Street 2:
Practice Address - City:KIEL
Practice Address - State:WI
Practice Address - Zip Code:53042-1281
Practice Address - Country:US
Practice Address - Phone:920-894-3322
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-01
Last Update Date:2024-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15537363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100285361Medicaid