Provider Demographics
NPI:1184192114
Name:JOHNSON, JORDAN KATHLEEN (PA-C)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:KATHLEEN
Last Name:JOHNSON
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 1:400 CONCORD PLAZA DR STE 300
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78216-6991
Mailing Address - Country:US
Mailing Address - Phone:210-804-5416
Mailing Address - Fax:210-678-4142
Practice Address - Street 1:2829 BABCOCK RD STE 700
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-6015
Practice Address - Country:US
Practice Address - Phone:210-804-5400
Practice Address - Fax:210-804-5633
Is Sole Proprietor?:No
Enumeration Date:2018-11-07
Last Update Date:2018-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA12344363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant