Individual
ANTIONETTE JORDAN
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
10004 KENNERLY RD STE 374B, SAINT LOUIS, MO 63128-2178
(314) 842-9669
(314) 842-1017
Mailing address
PO BOX 802841, KANSAS CITY, MO 64180-2841
(314) 842-9669
(314) 842-1017
Taxonomy
Speciality
Code
Description
License number
State
363L00000X
Nurse Practitioner
Primary
2022047351
MO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
2022047351
LICENSE
MO
05
—
420120169
—
MO
Enumeration date
01/24/2023
Last updated
08/06/2023
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