Provider Demographics
NPI:1790729614
Name:JORDAN, JEREMY TODD (PA-C, MBA)
Entity Type:Individual
Prefix:MR
First Name:JEREMY
Middle Name:TODD
Last Name:JORDAN
Suffix:
Gender:M
Credentials:PA-C, MBA
Other - Prefix:
Other - First Name:TODD
Other - Middle Name:
Other - Last Name:JORDAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C, MBA
Mailing Address - Street 1:2300 MACCORKLE AVE SE
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25304-1099
Mailing Address - Country:US
Mailing Address - Phone:304-357-4790
Mailing Address - Fax:
Practice Address - Street 1:3200 MACCORKLE AVE SE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25304-1297
Practice Address - Country:US
Practice Address - Phone:304-388-5432
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2021-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV823363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q04424Medicare UPIN
WVJOPA79141Medicare ID - Type Unspecified
JOPA30572Medicare PIN
JOPA79141Medicare PIN