Provider Demographics
NPI:1396217675
Name:KINGDON, JORDAN NICOLE (PA)
Entity Type:Individual
Prefix:MS
First Name:JORDAN
Middle Name:NICOLE
Last Name:KINGDON
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 1:23 HILLSIDE RD
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06798-4021
Mailing Address - Country:US
Mailing Address - Phone:860-689-3908
Mailing Address - Fax:
Practice Address - Street 1:1650 DIXWELL AVE
Practice Address - Street 2:
Practice Address - City:HAMDEN
Practice Address - State:CT
Practice Address - Zip Code:06514-3615
Practice Address - Country:US
Practice Address - Phone:203-288-1700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-26
Last Update Date:2018-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT4352Medicaid