Provider Demographics
NPI:1487378949
Name:JORDAN, JEREMY W (PA)
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:W
Last Name:JORDAN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11711 COLLETT AVE APT 531
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92505-3771
Mailing Address - Country:US
Mailing Address - Phone:707-540-3712
Mailing Address - Fax:
Practice Address - Street 1:11711 COLLETT AVE APT 531
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92505-3771
Practice Address - Country:US
Practice Address - Phone:707-540-3712
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-28
Last Update Date:2022-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0007579363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant