Provider Demographics
NPI:1598062713
Name:O'CONNOR, JORDAN (PA)
Entity Type:Individual
Prefix:MISS
First Name:JORDAN
Middle Name:
Last Name:O'CONNOR
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:JORDAN
Other - Middle Name:
Other - Last Name:MANLY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:BOX 85
Mailing Address - Street 2:55 FOGG RD
Mailing Address - City:WEYMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02190
Mailing Address - Country:US
Mailing Address - Phone:781-624-3889
Mailing Address - Fax:781-624-6730
Practice Address - Street 1:55 FOGG RD
Practice Address - Street 2:
Practice Address - City:WEYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02190
Practice Address - Country:US
Practice Address - Phone:781-624-3889
Practice Address - Fax:781-624-6730
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-24
Last Update Date:2015-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPA4141363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant