Provider Demographics
NPI:1881362242
Name:JORDAN, LESLIE ALLEN (CRNA)
Entity type:Individual
Prefix:MRS
First Name:LESLIE
Middle Name:ALLEN
Last Name:JORDAN
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4421 AUDUBON PARK DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39211-6136
Mailing Address - Country:US
Mailing Address - Phone:601-927-4845
Mailing Address - Fax:
Practice Address - Street 1:4421 AUDUBON PARK DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39211-6136
Practice Address - Country:US
Practice Address - Phone:601-927-4845
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-01
Last Update Date:2024-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X390200000X
MS901912367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program