Provider Demographics
NPI:1396418596
Name:ROSE, JORDAN
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:ROSE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JORDAN
Other - Middle Name:
Other - Last Name:DOUCET
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:106 GOLMON CIR
Mailing Address - Street 2:
Mailing Address - City:DAPHNE
Mailing Address - State:AL
Mailing Address - Zip Code:36526-7050
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:106 GOLMON CIR
Practice Address - Street 2:
Practice Address - City:DAPHNE
Practice Address - State:AL
Practice Address - Zip Code:36526-7050
Practice Address - Country:US
Practice Address - Phone:251-802-5858
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-26
Last Update Date:2023-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL2141363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant