Provider Demographics
NPI:1851764807
Name:EDELEN, JORDAN M (PAC)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:M
Last Name:EDELEN
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:100 E LIBERTY ST
Mailing Address - Street 2:SUITE 800
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-1434
Mailing Address - Country:US
Mailing Address - Phone:502-749-7909
Mailing Address - Fax:502-749-9397
Practice Address - Street 1:908 DUPONT RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4602
Practice Address - Country:US
Practice Address - Phone:502-749-7909
Practice Address - Fax:502-749-9397
Is Sole Proprietor?:No
Enumeration Date:2015-11-12
Last Update Date:2018-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA2072363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100375380Medicaid
KY7100375380Medicaid