Provider Demographics
NPI:1619370160
Name:OLESNAVICH, JORDAN L (PA-C)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:L
Last Name:OLESNAVICH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JORDAN
Other - Middle Name:L
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:830 W LAKE LANSING RD
Mailing Address - Street 2:STE. 190
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48823-6371
Mailing Address - Country:US
Mailing Address - Phone:517-333-3777
Mailing Address - Fax:517-203-3956
Practice Address - Street 1:830 W LAKE LANSING RD STE 190
Practice Address - Street 2:
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823-6371
Practice Address - Country:US
Practice Address - Phone:517-333-3777
Practice Address - Fax:517-209-3976
Is Sole Proprietor?:No
Enumeration Date:2014-09-29
Last Update Date:2018-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085005249363AM0700X
MI5601007728363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical