Provider Demographics
NPI:1578913976
Name:JORDAN, GRAYSON
Entity Type:Individual
Prefix:
First Name:GRAYSON
Middle Name:
Last Name:JORDAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 100174
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29202-3174
Mailing Address - Country:US
Mailing Address - Phone:864-512-7879
Mailing Address - Fax:864-512-7037
Practice Address - Street 1:21 S SHIRLEY AVE
Practice Address - Street 2:
Practice Address - City:HONEA PATH
Practice Address - State:SC
Practice Address - Zip Code:29654-1503
Practice Address - Country:US
Practice Address - Phone:864-512-7879
Practice Address - Fax:864-512-7037
Is Sole Proprietor?:No
Enumeration Date:2016-06-16
Last Update Date:2023-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCLL39787207Q00000X
SC39787207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine