Provider Demographics
NPI:1710424254
Name:STORES, JORDAN (PA-C)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:STORES
Suffix:
Gender:M
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 1:1959 MOORINGS CIR
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURG
Mailing Address - State:FL
Mailing Address - Zip Code:32068-6645
Mailing Address - Country:US
Mailing Address - Phone:904-662-0310
Mailing Address - Fax:
Practice Address - Street 1:1544 COUNTY ROAD 220 STE 100
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32003-4991
Practice Address - Country:US
Practice Address - Phone:904-223-2340
Practice Address - Fax:904-637-7991
Is Sole Proprietor?:No
Enumeration Date:2017-01-23
Last Update Date:2023-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
FLPA9113597363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant