Provider Demographics
NPI:1356005128
Name:HART, JORDAN KENDALL (PA-C)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:KENDALL
Last Name:HART
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 1:14025 N EASTERN AVE APT 2912
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73013-3520
Mailing Address - Country:US
Mailing Address - Phone:405-513-3531
Mailing Address - Fax:
Practice Address - Street 1:11000 HEFNER POINTE DR
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73120-5039
Practice Address - Country:US
Practice Address - Phone:405-749-9655
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-27
Last Update Date:2021-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4664363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant