Provider Demographics
NPI:1790885341
Name:JORDAN, GLEN S (PA-C)
Entity Type:Individual
Prefix:MR
First Name:GLEN
Middle Name:S
Last Name:JORDAN
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 1:1340 HAL GREER BLVD
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25701-3804
Mailing Address - Country:US
Mailing Address - Phone:304-399-6727
Mailing Address - Fax:304-399-6726
Practice Address - Street 1:1340 HAL GREER BLVD
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25701-3804
Practice Address - Country:US
Practice Address - Phone:304-399-6727
Practice Address - Fax:304-399-6726
Is Sole Proprietor?:No
Enumeration Date:2006-09-24
Last Update Date:2021-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV01222363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVP00711764OtherMEDICARE RR
OH0080124Medicaid
KY7100118540Medicaid
WV1790885341Medicaid