Provider Demographics
NPI:1033573464
Name:SHEALY, JORDAN ANDREW (MD)
Entity Type:Individual
Prefix:DR
First Name:JORDAN
Middle Name:ANDREW
Last Name:SHEALY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1924 ALCOA HWY # U-11
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37920-1511
Mailing Address - Country:US
Mailing Address - Phone:865-305-9230
Mailing Address - Fax:865-305-8894
Practice Address - Street 1:130 GLENDALE DR W
Practice Address - Street 2:
Practice Address - City:WILSON
Practice Address - State:NC
Practice Address - Zip Code:27893-2770
Practice Address - Country:US
Practice Address - Phone:252-399-7557
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-12
Last Update Date:2021-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN390200000X
NC2021-02023208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program