Provider Demographics
NPI:1639136997
Name:JORDAN, TERRI GURROLA (PA-C, MPAS, APA)
Entity Type:Individual
Prefix:
First Name:TERRI
Middle Name:GURROLA
Last Name:JORDAN
Suffix:
Gender:F
Credentials:PA-C, MPAS, APA
Other - Prefix:
Other - First Name:TERRI
Other - Middle Name:LYNN
Other - Last Name:GURROLA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C, MPAS, APA
Mailing Address - Street 1:7901 VETERANS PKWY
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31909-1723
Mailing Address - Country:US
Mailing Address - Phone:706-321-1223
Mailing Address - Fax:706-321-0819
Practice Address - Street 1:700 CENTER ST
Practice Address - Street 2:SUITE 102
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31901
Practice Address - Country:US
Practice Address - Phone:706-571-1011
Practice Address - Fax:706-320-8646
Is Sole Proprietor?:No
Enumeration Date:2006-04-28
Last Update Date:2018-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003981363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAP73404Medicare UPIN