Provider Demographics
NPI:1558031864
Name:GREEN, JORDAN J (PA-C)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:J
Last Name:GREEN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:660 GOLDEN RIDGE RD STE 250
Mailing Address - Street 2:
Mailing Address - City:GOLDEN
Mailing Address - State:CO
Mailing Address - Zip Code:80401-9541
Mailing Address - Country:US
Mailing Address - Phone:303-233-1223
Mailing Address - Fax:303-233-8755
Practice Address - Street 1:660 GOLDEN RIDGE RD STE 250
Practice Address - Street 2:
Practice Address - City:GOLDEN
Practice Address - State:CO
Practice Address - Zip Code:80401-9541
Practice Address - Country:US
Practice Address - Phone:303-233-1223
Practice Address - Fax:303-233-8755
Is Sole Proprietor?:No
Enumeration Date:2021-09-17
Last Update Date:2023-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10003309A363AM0700X
COPA.0007717363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical