Provider Demographics
NPI:1659922250
Name:WHITAKER, JORDAN DALE (PA)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:DALE
Last Name:WHITAKER
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1770 LAKE CUMBERLAND RD
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:KY
Mailing Address - Zip Code:40456-8431
Mailing Address - Country:US
Mailing Address - Phone:606-256-7488
Mailing Address - Fax:606-256-8036
Practice Address - Street 1:1770 LAKE CUMBERLAND RD
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:KY
Practice Address - Zip Code:40456-8431
Practice Address - Country:US
Practice Address - Phone:606-256-7488
Practice Address - Fax:606-256-8036
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-25
Last Update Date:2019-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYTC870363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant