Provider Demographics
NPI:1124389895
Name:HALL, JORDAN LEE (PA)
Entity Type:Individual
Prefix:MR
First Name:JORDAN
Middle Name:LEE
Last Name:HALL
Suffix:
Gender:M
Credentials:PA
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Mailing Address - Street 1:5671 PEACHTREE DUNWOODY RD NE
Mailing Address - Street 2:SUITE 900
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-5000
Mailing Address - Country:US
Mailing Address - Phone:404-847-9999
Mailing Address - Fax:404-531-8466
Practice Address - Street 1:5671 PEACHTREE DUNWOODY RD NE
Practice Address - Street 2:SUITE 900
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-5000
Practice Address - Country:US
Practice Address - Phone:404-847-9999
Practice Address - Fax:404-531-8466
Is Sole Proprietor?:No
Enumeration Date:2012-05-30
Last Update Date:2013-02-19
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
GA002284363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003127649BMedicaid
GA202I973921Medicare PIN