Provider Demographics
NPI:1164112389
Name:JORDAN, EMILY GRACE
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:GRACE
Last Name:JORDAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3601 LADSON RD
Mailing Address - Street 2:
Mailing Address - City:LADSON
Mailing Address - State:SC
Mailing Address - Zip Code:29456-4304
Mailing Address - Country:US
Mailing Address - Phone:843-303-7244
Mailing Address - Fax:
Practice Address - Street 1:3601 LADSON RD
Practice Address - Street 2:
Practice Address - City:LADSON
Practice Address - State:SC
Practice Address - Zip Code:29456-4304
Practice Address - Country:US
Practice Address - Phone:843-285-2500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-10
Last Update Date:2023-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant