Provider Demographics
NPI:1609359215
Name:VANDENBERG, JORDAN MCKENZIE (PA)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:MCKENZIE
Last Name:VANDENBERG
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:JORDAN
Other - Middle Name:MCKENZIE
Other - Last Name:CREED
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 749495
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-9495
Mailing Address - Country:US
Mailing Address - Phone:239-432-8331
Mailing Address - Fax:813-321-1296
Practice Address - Street 1:580 N CAMINO MERCADO
Practice Address - Street 2:
Practice Address - City:CASA GRANDE
Practice Address - State:AZ
Practice Address - Zip Code:85122-5757
Practice Address - Country:US
Practice Address - Phone:520-876-0416
Practice Address - Fax:520-421-3474
Is Sole Proprietor?:No
Enumeration Date:2018-09-10
Last Update Date:2023-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7283363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant