1649783705 NPI number — JORDAN BRUSH MCCREARY FNP-BC

Table of content: JORDAN BRUSH MCCREARY FNP-BC (NPI 1649783705)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649783705 NPI number — JORDAN BRUSH MCCREARY FNP-BC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCCREARY
Provider First Name:
JORDAN
Provider Middle Name:
BRUSH
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
FNP-BC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
TAYLOR
Provider Other First Name:
JORDAN
Provider Other Middle Name:
BRUSH
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1649783705
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3211 FOUNTAIN PARK BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KNOXVILLE
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37917-2957
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
901-604-1851
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2018 W CLINCH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KNOXVILLE
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37916-2301
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
865-541-8000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/13/2017

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 163W00000X , with the licence number:  175432 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207PP0204X , with the licence number: 23519 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2080P0204X , with the licence number: 23519 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: 23519 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363L00000X , with the licence number: 23519 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 23519 . This is a "STATE TENNESSEE APRN LICENSE" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 2017025275 . This is a "ANCC" identifier . This identifiers is of the category "OTHER".