| Doctor Name: | MR. CHARLES RAYMOND JORDAN |
| NPI Number: | 1306126263 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | FNP |
| License Number: | R869908 |
| Business Practice Address: | 1350 Sunset Dr Ste B Grenada, MS - 389014079 |
| Business Phone Number: | 6624663632 |
| Business Fax Number: | |
| Mailing Address: | Po Box 395, N.CARROLLTON |
| State: | MS |
| Postal Code: | 389470395 |
| Phone Number: | 6624663632 |
| Fax Number: | |
| NPI Enumeration Date: | 08/24/2011 |
| NPI Last Update Date: | 08/24/2011 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 363LF0000X |
| License Number: | R869908 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | MS |
| Taxonomy Type: | Physician Assistants & Advanced Practice Nursing Providers |
| Taxonomy Classification: | Nurse Practitioner |
| Taxonomy Specialization: | Family |
| Taxonomy Definition: | |