Provider Demographics
NPI:1811418734
Name:JUPENA, JORDAN LUCILLE (PA-C)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:LUCILLE
Last Name:JUPENA
Suffix:
Gender:F
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 1:4815 LIBERTY AVE STE 439
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15224-2156
Mailing Address - Country:US
Mailing Address - Phone:412-578-3925
Mailing Address - Fax:412-605-6364
Practice Address - Street 1:4815 LIBERTY AVE STE 439
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15224-2156
Practice Address - Country:US
Practice Address - Phone:412-578-3925
Practice Address - Fax:412-605-6364
Is Sole Proprietor?:No
Enumeration Date:2017-06-30
Last Update Date:2020-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AM0700X
PAMA059117363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103325844Medicaid
14055112OtherCAQH