Provider Demographics
NPI:1679241400
Name:BREISCH, JORDAN (PA-C)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:BREISCH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:675 N SAINT CLAIR ST STE 15-200
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-5967
Mailing Address - Country:US
Mailing Address - Phone:312-695-8182
Mailing Address - Fax:312-695-4303
Practice Address - Street 1:675 N SAINT CLAIR ST STE 15-200
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-5967
Practice Address - Country:US
Practice Address - Phone:312-695-8182
Practice Address - Fax:312-695-4303
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-07
Last Update Date:2022-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10003401A363A00000X
IL085008989363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant