Provider Demographics
NPI:1710115993
Name:GARRISON, JORDAN LEIGH (DO)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:LEIGH
Last Name:GARRISON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:246 PARKS HALL
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:OH
Mailing Address - Zip Code:45701
Mailing Address - Country:US
Mailing Address - Phone:740-593-2516
Mailing Address - Fax:740-593-2905
Practice Address - Street 1:246 PARKS HALL
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:OH
Practice Address - Zip Code:45701
Practice Address - Country:US
Practice Address - Phone:740-593-2516
Practice Address - Fax:740-593-2905
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-26
Last Update Date:2012-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH390200000X
OH34010594207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program