Provider Demographics
NPI:1093888687
Name:JORDAN, QUINCY JEROME SR (MD)
Entity Type:Individual
Prefix:DR
First Name:QUINCY
Middle Name:JEROME
Last Name:JORDAN
Suffix:SR
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 1:509 SUMTER ST
Mailing Address - Street 2:
Mailing Address - City:MONTEZUMA
Mailing Address - State:GA
Mailing Address - Zip Code:31063-1733
Mailing Address - Country:US
Mailing Address - Phone:478-472-3100
Mailing Address - Fax:478-472-3248
Practice Address - Street 1:509 SUMTER ST
Practice Address - Street 2:
Practice Address - City:MONTEZUMA
Practice Address - State:GA
Practice Address - Zip Code:31063
Practice Address - Country:US
Practice Address - Phone:478-472-3100
Practice Address - Fax:478-472-3248
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-15
Last Update Date:2018-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA033367207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAE83893Medicare UPIN