Provider Demographics
NPI:1790337046
Name:BLACKHAM, JORDAN LEE (PA-C)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:LEE
Last Name:BLACKHAM
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:3155 S HIDDEN VALLEY DR UNIT 333
Mailing Address - Street 2:
Mailing Address - City:SAINT GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84790-6986
Mailing Address - Country:US
Mailing Address - Phone:435-262-0497
Mailing Address - Fax:
Practice Address - Street 1:652 S MEDICAL CENTER DR STE 120
Practice Address - Street 2:
Practice Address - City:SAINT GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84790-7077
Practice Address - Country:US
Practice Address - Phone:435-251-3600
Practice Address - Fax:435-251-3601
Is Sole Proprietor?:No
Enumeration Date:2019-07-16
Last Update Date:2020-11-06
Deactivation Date:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program