Provider Demographics
NPI:1023384401
Name:WILKINS, JORDAN MICHAEL
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:MICHAEL
Last Name:WILKINS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 788263
Mailing Address - Street 2:
Mailing Address - City:TWENTYNINE PALMS
Mailing Address - State:CA
Mailing Address - Zip Code:92278-8263
Mailing Address - Country:US
Mailing Address - Phone:760-830-7017
Mailing Address - Fax:
Practice Address - Street 1:1546 6TH
Practice Address - Street 2:
Practice Address - City:TWENTYNINE PALMS
Practice Address - State:CA
Practice Address - Zip Code:92277
Practice Address - Country:US
Practice Address - Phone:760-830-2621
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-29
Last Update Date:2021-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman