Provider Demographics
NPI:1053074781
Name:JORDAN, KAITLIN (PA-C)
Entity Type:Individual
Prefix:
First Name:KAITLIN
Middle Name:
Last Name:JORDAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:558 S FREDERICK AVE APT 241
Mailing Address - Street 2:
Mailing Address - City:GAITHERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20877-6320
Mailing Address - Country:US
Mailing Address - Phone:901-581-9995
Mailing Address - Fax:
Practice Address - Street 1:604 S FREDERICK AVE STE 211
Practice Address - Street 2:
Practice Address - City:GAITHERSBURG
Practice Address - State:MD
Practice Address - Zip Code:20877-1282
Practice Address - Country:US
Practice Address - Phone:410-823-6408
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-19
Last Update Date:2021-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0008219363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant