Provider Demographics
NPI:1164534699
Name:JORDAN, JENNIFER JEAN (PA)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:JEAN
Last Name:JORDAN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5145 FM 620 N STE B-110
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78732-1815
Mailing Address - Country:US
Mailing Address - Phone:512-266-0007
Mailing Address - Fax:512-266-0077
Practice Address - Street 1:5145 FM 620 N STE B-110
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78732-1815
Practice Address - Country:US
Practice Address - Phone:512-266-0007
Practice Address - Fax:512-266-0077
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2020-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA04718207NS0135X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00393129OtherRAILROAD MEDICARE
TXTXB140160Medicare PIN
8G4630Medicare PIN