Provider Demographics
NPI:1639690126
Name:WOOD, JORDAN LEE (FNP)
Entity Type:Individual
Prefix:MR
First Name:JORDAN
Middle Name:LEE
Last Name:WOOD
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
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Mailing Address - Street 1:1835 SAVOY DR STE 300
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30341-1071
Mailing Address - Country:US
Mailing Address - Phone:478-745-6130
Mailing Address - Fax:478-745-4443
Practice Address - Street 1:308 COLISEUM DR STE 120
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31217-3859
Practice Address - Country:US
Practice Address - Phone:478-745-6130
Practice Address - Fax:478-745-4443
Is Sole Proprietor?:No
Enumeration Date:2017-07-05
Last Update Date:2020-08-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GARN231069363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003210385AMedicaid
GA003210385BMedicaid
GAG06315BOtherMEDICARE PTAN